The GTVPET was delineated automatically by using various percentages relative to the maximal SUV and absolute SUV. The optimal threshold SUV was further obtained as the value at which the GTVPET best matched with the GTVPATH.Ten patients with the cervical cancer who underwent surgery were enrolled in this study. The excised specimens were processed for whole-mount serial sections and H-E staining. The tumor borders were outlined in sections under a microscope, histopathological images were scanned and the GTVPATH was 13.38±2.80 cm3 on average. The optimal threshold on percentile SUV and absolute SUV were 40.50%±3.16% and 7.45±1.10, respectively. The correlation analysis showed that the optimal percentile SUV threshold was inversely correlated with GTVPATH (p<0.05) and tumor diameter (p<0.05). The absolute SUV was also positively correlated with SUVmax (p<0.05).An average of 85±10% shrinkage of tissue was observed after the formalin fixation. The GTVPATH as standard for cervical cancer target volume delineation was thus determined in this study, and more cases are being evaluated to substantiate this conclusion.The pathological volume could provide the more accurate tumor volume. The optimal SUV of FDG for PET imaging by use of GTV The FDG uptake increases in the cells with high metabolic rate, especially in tumor region, which appears as high-uptake hot spots in FDG-PET image. This imaging technique has been extensively evaluated and widely used for early diagnosis, staging, confirmation of lymph node metastasis and radiotherapy outcome in the cervical cancer The fluorine-18 fluorodeoxyglucose positron emission tomography  on CT, the volume of GTVIn this study, we have compared the volume based on the PET/CT functional imaging information of the cervical cancer with the pathologic volume reconstructed by a technique of whole-mount serial sections. The aim of this study was to explore feasibility of using the reconstructed pathologic volume as the standard to determine the optimal SUV cutoff-value of PET/CT images and to provide an experimental basis for delineating biological target volume of cervical cancer. At the same time, the range of microscopic extension in the different directions of the cervical cancer was observed under a microscope to observe boundary of clinical target volume. To our knowledge, this is the first report on correlation of image-based radiotherapy target volume and reconstructed pathologic volume of the cervical cancer.18F-FDG-PET/CT scans on the day before surgery. The protocol was approved by Hospital's Protection of Human Subjects Committee , and written consent was taken from all the patients.Ten patients with histologically confirmed cervical cancer were selected for the present study at the Xijing Hospital between March 2010 and November 2010. The eligibility criteria were included as invasive squamous cell carcinoma with FIGO clinical stageIB-IIB. The patients were free of diabetes or other diseases that could affect the results of FDG-PET/CT, and had not undergone any cancer-related treatments previously. All patients underwent radical hysterectomy and pelvic lymphadenectomy and the 18F-FDG (5.55–7.40MBq/kg), the CT image scan was extended from L3 to tuber ischiadicum by using 64-slice helical CT acquisition  and emission images were acquired covering the same axial range. The PET images were reconstructed with CT-derived attenuation correction using ordered-subset expectation maximization software.The FDG-PET/CT scan was performed with a hybrid PET/CT scanner . All patients were asked to fast for at least 6 h before the PET examination and their blood glucose levels were checked before injecting the tracer. About forty to sixty minutes after intravenous injection of PET(SUV)) was calculated automatically by the True-D Software at various cut-off level of the absolute SUV, from 2.5 to 12.5 at 0.5 intervals ) was calculated by same way at different percentile thresholds of the maximal SUV, from 10% to 60% at 5% interval  being >2.5). The gross target volume confirmed by absolute SUV level (GTVPATH) was calculated according to summation formula, i.e. GTVPATH  =  Σ area × thickness/R, in which R was defined as the ratio of the sample dimensions before and after formalin fixation.All the patients underwent radical hysterectomy and pelvic lymphadenectomy. The tumor maximum diameter and vertical diameter were measured and recorded . Once thPATH with the GTVPET(SUV) and GTVPET(%SUV) were compared case by case. A coordinate system was established with the vertical axis of absolute SUV or percentile SUV threshold and abscissa of GTVPET. A linear approximation could be seen between the adjacent two points in coordinate system. The GTVPET(SUV) and GTVPET(%SUV) were obtained best in agreement with GTVPATH by a first-order linear approximation  and GTVPET(%SUV) with the corresponding GTVPATH. Spearman correlation test was used to analyze relationship between optimal cut-off absolute SUV or percentile SUV threshold, tumor maximum diameter and GTVPATH. The cases satisfying p<0.05 were considered as statistically significant for all comparison tests in this study.All data were statistically analyzed by SPSS software (version 13.0) in this study. Wilconxon signed-rank test was used to compare GTVB, 3 of IIA and 5 of IIB. All patients exhibited abnormal radioactive uptake in tumor (SUV>2.5). No patient showed abnormal lymph nodes in the pelvic cavity.All the patients were confirmed with the invasive squamous carcinoma of cervix. The median age of 10 patients was 40 years (ranging 32–55 years). The clinical stage (FIGO): 2 of IThe volume of tissue changed during the pathological procedure. A notable shrinkage of tissue occurred during the formalin fixation procedure. The mean volume of tumor after fixation was about 85%±10% (ranging 65–97%) of the original tumor volume .max and SUVmean were 18.38±8.85 and 7.88±2.85, respectively. The SUV values varied among patients. The range of absolute SUV threshold was from 3.8 to 13.0 and the mean of optimal absolute SUV was 7.45±1.10. The percentile SUV threshold was from 24.9% to 55% and the mean of optimal percentile SUV was 40.50%±3.16%  (p = 0.0072)   and tumo 0.0072) .p = 0.0126). The percentile SUV threshold for tumors of different pathologic volumes was 32.83%±10.02% for tumors being >15 cm3, 35.70%±1.71% for tumor volume ranging between 5–15 cm3, and 49.9%±5.67% for tumors being <5 cm3, respectively (p = 0.0224).There was a significant difference of the percentile SUV among the different tumor diameters or different pathologic volumes. When they were divided tumor into three groups by diameter, i.e. <2.5 cm, 2.5–4.5 cm, and >4.5 cm, the optimal percentile SUV was 52.4%±3.08%, 37.33%±3.54% and 32.83%±10.02%, respectively (p = 0.8382) or volume . The optimal absolute SUV was 7.73±4.57 for tumor diameter being <2.5 cm, 6.89±3.32 for diameter being between 2.5 cm and 4.5 cm, and 7.90±4.00 for diameter being >4.5 cm, respectively (p = 0.9340). It was 7.90±4.00 for tumors of size >15 cm3, 5.32±1.32 for tumors of size 5–15 cm3, and 8.70±4.21 for tumors of size <5 cm3 (p  = 0.4829). The absolute SUV was positively correlated with SUVmax  .On the other hand, there was no significant correlation between the optimal absolute SUV value and tumor diameter  . HoweverPET) matched best to the pathological volume(GTVPATH) in the cervical cancer. By using whole-mount serial section technique, it revealed that shrinkage rate of tumor volume was from 65% to 97% (mean 85±10%) after pathological process and actual volume of tumor was obtained by reconstruction procedure. Data of this study indicate that the actual tumor volume could be considered as more accurate volume and be potentially used as “the gold standard” to compare PET volume and further to determine the optimal SUV value in PET images for radiotherapy of cervical cancer.The novelty of the present piece of study is that pathological volume could provide the more accurate tumor volume and the PET-defined gross tumor volume  ratios 18F-FDG The common methods confirming SUV value on PET imaging are roughly divided into three types. They included one studying the phantom, one comparing with other types of image, and one comparing with tumor size determined by pathological volume. Through phantom studies, the researchers found an optimal SUV thresholds for PET as between 36% to 44% for sphere volume larger than 4 mmet al compared the GTVs with confirmation of four methods in 25 patients with primary non small cell lung carcinoma (NSCLC), and found that a threshold of 40% of the maximum standardized uptake value was not suitable for target volume delineation et al reported that a single standardized uptake value threshold was not adequate for NSCLC et al recommended a method using SUV being ≥2.5 for radiotherapy planning in NSCLC by comparing with CT max in 6 NSCLC patients. They found an SUV contour of 2.5 was most closely correlated with the mean GTV defined by the interobservers To obtain the best SUV value, there were many studies comparing PET image with other type of image, especially CT, which was most commonly used to delineate the target volume for radiotherapy planning. Nestle U et al studied the correlation of PET SUV with pathologic specimen size in patients with head-and-neck cancers. They drew a conclusion that the SUV40 method might appear to offer balance between accuracy and reducing risk of underestimating tumor extent et al found an optimal threshold of 31%±11% and an absolute SUV of 3.0±1.6, respectively Furthermore, some researchers calculated the actual tumor volume and used it as a reference standard to find best SUV value. Burri RJ max of FDG PET in four different sites and found that no common SUVmax threshold exists In previous feasibility studies, a threshold of 40%–50% of maximum SUV was found to be a reliable correlate to tumor volume measured by CT PATH and tumor diameter in our study, which was well consistent with previous report in NSCLC CTIn this study, data showed that optimal percentile threshold SUV varied with changes of tumor volume. The optimal percentile threshold SUV reduced when the tumor volume increased, although the differences were not significant statistically. In contrast, no correlation was observed between the absolute SUV and tumor size of the cervical cancer. The optimal percentile threshold SUV showed an inverse correlation with GTVTo the best of our knowledge, there are few research reports comparing tumor volumes determined by different imaging modalities with surgical specimens in the cervical squamous cell tumors, and we thus concluded that GTVs derived from the PET images matched those from microscopy more accurately PET and GTVPATH in the cervical cancers. Data analysis indicated that pathological volume provided a more accurate tumor volume. The optimal SUV of PET imaging is thus proposed to use GTVPATH as standard for cervical cancer target volume delineation for improving the radiotherapy planning. Currently, more cervical cancer cases are being investigated to substantiate this conclusion.In this study, the SUV of 18F-FDG-PET image was studied by comparing GTV


The aim of the present investigation was to explore probable association of renal artery stenosis (RAS) with coronary artery disease (CAD) and the prevalence of renal artery stenosis (RAS) in patients with CAD.This study comprised 165 consecutive patients with CAD, including 52.7% males and 47.2% females with respective mean ages of 60.3 ±8.9 and 59.5±10.1. The patients underwent simultaneous coronary and renal angiographies, and the lumen reduction of 50% or more was considered as significant stenosis. Indeed, stenosis of more than 70% of the arterial lumen was regarded as severe.According to our findings, the prevalence of renal artery stenosis in our hypertensive and normotensive patients were 46.2% and 19.5% respectively (p=0.002). Renal artery angiography revealed that 64 (38.8%) of the patients had simultaneous renal artery stenosis. RAS is more common in females than males (p=0.031). Multivariate analysis revealed that among all examined factors, hypertension and serum creatinine were associated with RAS. There was no correlations found between gensini score and RAS (p=0.63).We found a relatively high prevalence of RAS including 46.2% in hypertensive and 19.5% in normotensive patients in our patients with CAD. Atherosclerosis is a diffuse process characterized by functional and morphologic changes of the arterial wall including endothelial dysfunction, increased wall thickness and progressive plaque formation ,2. AlthoThe initial clinical presentation of coronary artery disease (CAD) may be abrupt due to plaque rupture with varying amounts of superimposed thrombus, vasoconstriction, and distal embolization, leading to acute coronary events, such as angina pectoris (AP) or myocardial infarction (MI) -5.As mentioned above, atherosclerosis can occurs in renal arteries leading to renal artery stenosis which is an important cause of secondary hypertension and also a main reason for renal failure in elderly. As investigated, 60-97% of renal artery stenosis in different areas are due to atherosclerosis .Angiography is the gold standard method for evaluation of stenosis in arteries in which it is used widely for detecting coronary artery obstruction . It is sBetween September 2010 and May 2011, 165 consecutive patients with CAD admitted to our department for coronary angiography were enrolled in this study. All the patients were selected and underwent coronary angiography according to American Heart Association and American College of Cardiology (AHA/ACC) guidelines. Renal angiography was also performed in all patients and during one session using a Siemens highcore system . All coronary angiographic examinations were performed by the Seldinger technique through femoral artery access. Angiographies were carried out in several views that best displayed the lesion and enabled stenosis grade evaluation. Intra-arterial systolic and diastolic pressures of the ascending aorta were measured during cardiac catheterization. In patients with creatinine level 1.5 mg/dl or less and significant coronary artery disease , abdominal aortography was conducted using a pigtail catheter with a pump injector. Whenever difficult to evaluate the degree of stenosis , selective renal arteriography was performed with a right 6 or 7 French Judkins catheter in the anterior–posterior, and when necessary in oblique projection. Lumen reduction of 50% and more was considered as significant stenosis. Indeed, stenosis more than 70% of the arterial lumen was considered as severe stenosis. All angiograms were analyzed by an experienced interventional cardiologist and together with another analyst who reviewed the angiograms reached a consensus. Patients were classified as having single vessel disease (1VD), two vessles disease (2VD) and three vessels disease (3VD) if they had a significant stenosis in 1, 2, and 3 major epicardial coronary vessels . Left main lesions counted as 2VD were considered present when luminal diameter was reduced by 50%.Fasting blood sugar (FBS), serum total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglycerides (TG) and creatinine were measured in all patients . Hypercholesterolemia denoted total serum cholesterol more than 240 (mg/dl), and hypertriglyceridemia indicated triglycerides more than 200 (mg/dl). High LDL and low HDL were defined as more than 160 (mg/dl), and less than 35 (mg/dl) respectively. Patients with blood pressures higher than 140/90 mmHg or documented history of hypertension or antihypertensive therapy were considered as hypertensive. Serum creatinine level ≤1.4 mg/dl considered as normal value and patients with creatinine level >1.5 excluded from this study as well as patients who had undergone previous renal or coronary revascularization.Gensini’s score was also calculated for each patient as previously described . PatientStatistical analysis was performed using SPSS version 16.0.1 . Normality of data was evaluated with the Kolmogorov–Smirnov test. The results were expressed as mean ± SD for parametric and mean ± SEM for nonparametric data. The statistical differences between proportions were determined by χ2 analysis. Numerical data were evaluated using analysis of variance, followed by Tukey’s post hoc test. P value less than 0.05 was considered as significant. Pearson and Spearman correlation tests were used for parametric and nonparametric numeric data analysis respectively.Among 165 patients 52.7% were males and 47.2% females with respective mean ages of 60.3±8.9 and 59.5±10.1 years, and without any statistically significant difference between them. Of the patients under study,71 (43%) had diabetes mellitus (DM), 119 (72.1%) were hypertensive (HTN), 129 (78.2%) had hyperlipidemia (HLP), 63(38.2%) were cigarette smokers and 38 (23%) had family history of CAD. Patients’ creatinine level was 1.15±0.2. Of 165 (6.1%) patients,10(6.1%) had creatinine levels higher than normal range. Coronary angiography revealed that 50 patients (30.3%) had one vessel involved by atherosclerosis, 33 (20%) had 2 vessels, and 82 (49.7%) had three vessels disease. Seven patients(4.2%) had more than 50% stenosis in left main coronary artery that categorized as 2 vessels in absence of significant right coronary stenosis and 3 vessels with significant right coronary stenosis or left side dominancy. Renal artery angiography revealed that 64 (38.8%) of the patients had simultaneous renal artery stenosis which in 26 patients it was in the right renal artery, 26 in the left and 12 (7.3%) in both renal arteries. RAS was present in 64 patients, which was severe in 26 (40.6%). Results showed that RAS is more common in females than males (P=0.031). There was no relationship found between the number of stenotic coronary arteries and RAS severity (P>0.05). Also no correlations were observed between severity of coronary artery disease (gensini’s score) and renal artery stenosis (P=0.63)The means systolic and diastolic blood pressures of patients which measured during angiography were 151.7±27.5 and 82±12.5 respectively. There was no significant difference between the mean age of patients with or without RAS (P=0.9).However, the mean age of patients with HTN was significantly higher than normotensive patients (P<0.001), and the stratifying data for RAS revealed the same result, showing that the mean age of patients with HTN was significantly higher than normotensive patients in both RAS and non-RAS patients (P=0.001).Also the prevalence of RAS in hypertensive patients was more than normotensive patients (P=0.002). Indeed, patients with RAS had higher systolic and diastolic blood pressures and serum creatinine level with respective P values of 0.009, 0.006 and <0.001.As described above, we showed a total prevalence of 38.8% RAS in our patients. The prevalence of RAS in our hypertensive and normotensive patients were 46.2% and 19.5% respectively. The patients’ ejection fraction (EF) was 54.2% ±9.9. Multivariate analysis revealed that among all factors examined, hypertension and serum creatinine were associated with RAS, where in patients with CAD, higher blood pressure and higher serum creatinine levels are predisposing factors. There was no association between RAS and DM, HLP, smoking or family history with respective P values of 0.23, 0.15 , 0.13 and 0.87.The mean value of gensini score was 36.1±2.6. Analysis showed that serum creatinine level and cardiac EF was correlated with gensini scores . However, no correlations were found between gensini’s score and RAS percentage, RAS, systolic or diastolic blood pressure  .In the current study we explored the prevalence of RAS in patients with CAD and evaluated the relationships between RAS and CAD. Recent studies indicated that RAS was not a rare finding in patients with coronary artery disease and our results showed that about 39% of our patients with CAD had RAS besides CAD. Considering HTN, our results showed that the prevalence of RAS in patients with no history of HTN was about 19.5%. This finding was compatible with other studies reporting such prevalence rate as 15.7% to 42%. Some of these studies have used non-invasive methods to determine the prevalence of RAS and this is one of the reasons for high RAS prevalence found in their patients. However, some other studies showed lower prevalence of RAS ,14. Our Multivariate analysis revealed that there was strong association of RAS with hypertension and serum creatinine level. A trend towards a significant relationship between hypertension and the presence of RAS has previously been established. Hypertension was shown to be a risk factor for RAS as well as a possible clinical manifestation of the activated renin angiotensin system secondary to RAS ,17. HighOur study showed no association between the number of coronary involved vessels and the severity of the RAS but there are some studies showing significant association between them . AssociaOur data revealed no association between RAS and DM, HLP, family history of CAD or smoking. These findings are in line with other studies ,22.The limitation of our study was that it was performed on a group of patients with confirmed CAD, thus the results obtained cannot be extrapolated to other patients with peripheral vascular atherosclerosis without any evidence of CAD.We found a relatively high prevalence of RAS, 46.2% in hypertensive and 19.5% in normotensive patients, in our patients with CAD. This finding underlines the importance of further awareness of renal function in patients with CAD. More studies are suggested to determine the relationship between CAD, RAS and HTN, in order to avoid RAS mortality and morbidities among CAD patients. Concurrent renal and coronary angiographies might be of benefit to those with history of hypertension and higher creatinine levels and the patients with increased intra-arterial systolic and diastolic pressures detected during the procedure.


The mink enteritis virus (MEV) SD12/01 strain was isolated from a mink showing clinical and pathological signs of enteritis in Shandong, China, in 2012. The genome of MEV SD12/01 was sequenced and analyzed, which will promote a better understanding of the molecular epidemiology and genetic diversity of MEV field isolates in northern China. Parvovirus and the family Parvoviridae (Mink enteritis virus (MEV) is a member of the genus oviridae . MEV is oviridae . CurrentIn August of 2012, a MEV strain with high virulence, named MEV SD12/01, was isolated from a disease outbreak in a mink farm in Shandong Province, northern China. Tissue samples tested positive for MEV by PCR using primers targeting viral VP2. Sequence alignment was performed using Vector NTI 11 software .The whole genome of SD12/10, excluding a partial inverted terminal repeat sequence, was amplified by PCR with four primer pairs. The PCR products were gel purified using the AxyPrep DNA gel extraction kit (Axygen) and sequenced on a 3730xl DNA analyzer (Applied Biosystems). The genomic sequence of SD12/01 comprises 4,556 nucleotides (nt) containing two open reading frames (ORFs). ORF1 (nt 100 to 2106) encodes two nonstructural proteins (NS1 and NS2), and ORF2 (nt 2200 to 4368) encodes two structural proteins (VP1 and VP2) through alternative splicing of the same mRNAs.The genome sequence of SD12/01 shares 99.2%, 99.4%, and 99.7% nucleotide sequence identities with those of MEVB (accession no. FJ592174), Abashiri (accession no. D00765), and MEV/LN-10 (accession no. HQ694567), respectively (Nucleotide sequence alignments, using the Clustal V method and a BLAST search in GenBank, demonstrated that the NS1 segment of MEV SD12/01 had 98.2% to 99.8% identity among the gene sequences available in GenBank and the VP2 segment had 99.4% to 99.9% identity; all showed the highest homology with the corresponding genes from Jlin/2010 strain HQ883275, respectively. New mutations in the nonstructural protein NS1 and the structural protein VP2 have not been found yet. The strain SD12/01 is a prevalent strain in China and has the potential to be a candidate vaccine strain. The genome data of SD12/01 will be helpful for analyses of molecular epidemiology and the genetic diversity of MEV.KC713592.The genome sequence of MEV strain SD12/01 has been deposited in GenBank under the accession no.


N-category is now divided into N0, N1, N2 and N3. In this study, we aimed to validate the prognostic ability of the new N classification system in EC with positive lymph nodes in a Chinese population, and evaluate whether the new N classification system can help the decision-making for postoperative adjuvant therapy.The 7th edition of the American Joint Committee on Cancer / Union International Against Cancer (AJCC/UICC) TNM classification were switched to pathological stage 7th edition for this analysis. Patients with pathological stage T1-4N1-3M0 EC were selected. Kaplan-Meier method and Cox regression analysis were employed to compare overall survival (OS).From 2002 to 2008, thoracic EC who underwent oesophagectomy were retrospectively analysed. Patients pathological stage 6p<0.001). This was also present in patients receiving postoperative radiotherapy (p<0.001) and those undergoing postoperative chemotherapy (p<0.001). There was no marked difference in OS between patients receiving postoperative adjuvant therapy and surgery alone at the same postoperative pN-category, except that postoperative radiotherapy marginally improved OS in patients with pN2 and pN3 disease.A total of 545 patients met the inclusion criteria: 346 (63.5%) received oesophagectomy alone, 199 (36.5%) received oesophagectomy and adjuvant radiotherapy, and 36.1% (197/545) received oesophagectomy and adjuvant chemotherapy. Univariate analysis and multivariate analysis revealed significant difference in OS among patients at different postoperative pN-category (Our results validated the prognostic ability of new N classification system. The N-category is an independent prognostic factor in patients with resectable thoracic EC who were positive for lymph nodes in a Chinese population. Further studies are required to clarify the role of new N classification system in the decision-making for postoperative adjuvant therapy. Oesophageal cancer (EC) is the eighth most common cancer worldwide. In China, EC is the fourth most common cause of death and frequently found in the thorax, and 95% of EC is pathologically diagnosed as squamous cell carcinoma.5th edition of the American Joint Committee on Cancer / Union International Against Cancer (AJCC/UICC) TNM classification for EC only defines the pathologic nodal status based on the lymph node metastasis. The 7th edition of the AJCC/UICC TNM classification was published in 2010.th edition, N-category of the 7th edition were divided into pN0: no lymph node metastasis; pN1: metastasis in 1∼2 lymph nodes; pN2: metastasis in 3∼6 lymph nodes; pN3: metastasis in ≥7 lymph nodes. Increasing numbers of reports show that the numbers of positive lymph node was positively related to the prognosis.11The 6However, there are several problems to be considered before this new staging system is used to assess the prognosis of patients in Asia population. For example, most EC in Western countries is diagnosed as adenocarcinoma at the lower oesophagus or gastroesophageal junction but EC is squamous cell carcinoma in the majority of patients in Asia. Previous studies have shown that, when compared with adenocarcinoma patients, those with oesophageal squamous cell carcinoma have worse prognosis and a distinct pattern of lymphatic spread, and are susceptible to spread locally rather than systemically.th edition TNM classification system for EC was revised based on the retrospective analysis of pathologic data from patients treated with primary surgical resection alone. However, patients with positive lymph nodes receiving surgery alone usually have a poor prognosis, and thus adjuvant chemotherapy and/or radiotherapy have been introduced for the therapeutic strategies. Can new N classification be used to identify patients who may require adjuvant chemotherapy and/or radiotherapy? To our best knowledge, the prognostic impact of the 7th edition TNM classification system has been not evaluated in detail in EC patients undergoing postoperative adjuvant therapy.In addition, the 7The present study aimed to validate the prognostic ability of the new N classification system in patients with EC who were positive for lymph nodes in a Chinese population, and evaluate whether the new N classification system can help the decision-making for postoperative adjuvant therapy in this population.th edition of the American Joint Committee on Cancer / Union International Against Cancer (AJCC/UICC) TNM classification were switched to pathological stage 7th edition for this analysis. Patients with pathological stage T1-4N1-3M0 EC were recruited into the present study. Other essential conditions: no distant metastasis, no preoperative chemotherapy and/or radiotherapy, no invasion to cervical oesophagus and cardiac part of the stomach.From 2002 to 2008, thoracic EC who underwent oesophagectomy were retrospectively analysed. Patients pathological stage 6In addition, only patients who survived for more than 3 months after surgery were included in the present study. This was done to remove possible bias in favour of the adjuvant treatment group, because some of the patients who received surgery alone may have died in the perioperative period before receiving adjuvant therapy. Thus, patients treated with oesophagectomy with or without adjuvant therapy were enrolled.th edition). The stages of EC in these patients are shown in Tumour size and extent was coded primarily according to the operative medical record and pathological findings. Number of lymph node metastasis was determined based on pathological findings. This information was used for the tumour, node, metastasis (TNM) classification according to the American Joint Committee on Cancer (AJCC) classification system  for lesions at the middle/lower third of the oesophagus. Upper third lesions were treated by cervical anastomosis (Mckeown procedure). Most of patients underwent two-field lymphadenectomy. The number of lymph nodes harvested per case ranged from 6 to 96 (median 28). Pyloroplasty and feeding jejunostomy were not routinely done. A nasogastric tube was placed in each patient until anastomotic wound closed as assessed by oesophagography on post-operative day 14.In this study, all patients were recommended to receive some adjuvant treatment. As the role of postoperative adjuvant radiotherapy and/or chemotherapy in the treatment of oesophageal squamous cell carcinoma was controversial at the time of treatment for these patients, the postoperative adjuvant therapy was not mandatory. The utilization of postoperative adjuvant radiotherapy and /or chemotherapy was per individual physicians’ preference and the general physical conditions. A total of 197 patients received postoperative adjuvant chemotherapy (>2 cycles). Cisplatin and 5-fluorouracil were used most frequently (67%), although several other chemotherapeutics were also used. Postoperative adjuvant radiotherapy, if given, was initiated at 4∼5 weeks after surgery. Large T-shaped field encompassing bilateral supraclavicular fossa, mediastinum and tumour bed was used. Radiation was given through anteroposterior field first to 36 Gy at 2 Gy per fraction followed by parallel opposing oblique fields to 14 Gy to avoid the spinal cord. Ten MV photons were used to deliver the radiation to the mediastinum through the anteroposterior and oblique fields. The radiation dose in all cases was prescribed to the isocenter. The bilateral supraclavicular fossas were treated with 9–12 MeV electrons. In some cases, targets were reduced on the basis of patient’s condition or physician’s judgment.P<0.05 was considered statistically significant.Overall survival (OS) was determined as the time (in months) from the date of surgery to last follow-up or to September 1, 2010 for patients alive or to the date of death. Survival probability was calculated with Kaplan-Meier method and compared with log-rank test. Multivariate analysis was performed with Cox regression model. Variables in the analysis included gender, age, tumour size, pathologic T-stage, pathologic N-stage, tumour differentiation, postoperative radiotherapy and postoperative chemotherapy. Statistical analysis was performed using SPSS Version 13.0 . A value of two-sided th edition of TNM classification system, pN1 EC was found in 270 cases, pN2 EC in 188 and pN3 EC in 87 cases. The median age was 57 years (range: 36∼86 years). Median follow-up period for survived patients was 51 months (range 4∼93 months). The patients’ characteristics are presented in A total of 545 patients were included in the present study: 346 (63.5%) received surgery alone, 199 (36.5%) postoperative radiotherapy and 197 (36.1%) postoperative chemotherapy. The average number of dissected lymph nodes was 31.2±17.4 (mean±SD) nodes per case . The mean number of metastatic nodes was 4.1±1.9 . According to the 7p = 0.006). The median survival time was 31 months in patients receiving postoperative radiotherapy and 21 months in those undergoing surgery alone. The postoperative radiotherapy dramatically improved OS at 3 years from 38.3 to 45.8% when compared with surgery alone. However, the median survival time was decreased from 28 months to 23 months in patients receiving postoperative chemotherapy as accompanied by a decrease in 3-year OS from 43.1 to 37.1%, but without significant differences (p = 0.508).The median survival time was 26.5 months, and the 3-year OS rate was 41.0%. The postoperative radiotherapy was found to be significantly associated with improved OS (p < 0.001) and the 3-year OS rate was 51.5%, 37.5% and 13.8%, respectively (p < 0.001) (p < 0.001) and the 3-year OS rate was 53.3%, 45.7% and 16.9%, respectively (p < 0.001) (p < 0.001) and the 3-year OS rate was 50.9%, 31.2% and 15.4%, respectively (p < 0.001) , significant difference in OS were found among patients at different postoperative pN-category. The median survival time for pN1, pN2 and pN3 patients were 41 months, 23 months and 13 months, respectively (< 0.001) . Subgrou< 0.001) . Further< 0.001) .p = 0.507); 31.4% and 45.7%, respectively, in those at pN2 (p = 0.080); 8.6% and 16.9%, respectively, in those at pN3 (p = 0.064), only marginally improved OS for pN2 and pN3 disease. This was also noted between patients receiving postoperative chemotherapy and surgery alone. For patients receiving surgery alone and those undergoing concomitant postoperative chemotherapy, the 3-year OS was 52.8% and 50.9%, respectively, in patients at pN1 (p = 0.768); 40.6% and 31.2%, respectively, in those at pN2 (p = 0.570); 10.2% and 15.4%, respectively, in those at pN3 (p = 0.131)  .p < 0.001; pN3/pN1: HR 3.19, 95% CI 2.40–4.23, p < 0.001) was associated with survival. Postoperative radiotherapy was associated with improved survival . Male gender and high T stage predicted a decrease of OS . Postoperative radiotherapy was associated with improved survival . Male gender and high T stage predicted a decrease of OS  staging system. The major differences between the 6th and 7th editions include: (1) T is re-defined and T4 subclassified as T4A and T4B; (2) the regional lymph nodes are re-defined. N is subclassified according to the number of positive regional lymph nodes; (3) M is re-defined. In addition, prognostic staging, including histological grade and cancer location, are defined for T1-3N0M0 patients. However, the reliability and accuracy of the nodal portion of the TNM staging system still remains the much debate. Several studies have evaluated the influence of the number of lymph node metastasis on the prognosis of patients with esophageal cancer and have found significant differences in prognosis between the patients with different numbers.th edition TNM classification system, N classification independently affected the prognosis of thoracic EC patients with positive lymph nodes after radical surgery in Chinese population. This was also present in patients receiving postoperative radiotherapy (p < 0.001) and those undergoing postoperative chemotherapy (p < 0.001). Lymph node involvement is a significant prognostic indicator of overall survival, and as the number of involved nodes increases, it may suggest a greater tumour burden or more aggressive tumour biology, and so the likelihood of locoregional or systemic recurrence could be assumed to be higher.The oesophageal cancer TNM classification system was recently revised in the 7th edition, the postoperative pN-categories are re-defined based on the number of positive regional lymph nodes. Many studies have addressed the impact of postoperative radiotherapy on the prognosis of oesophageal squamous cell carcinoma patients based on the number of positive lymph nodes. Xiao et al.vs. 41.3% for postoperative radiotherapy; p = 0.4474). However, when patients were stratified based on the number of positive lymph nodes, obvious survival benefit was noted in patients receiving postoperative radiotherapy with an improvement in 5-year OS from 17.6 to 34.1%, (p = 0.0378). In patients with 1∼2 positive lymph nodes, the 5-year survival rate was 23.5% in the surgery alone group and 45.1% in the postoperative radiotherapy group (p = 0.1286). In patients with ≥3 positive lymph nodes, the 5-year survival rate was 0% and 20.6% in the surgery alone group and postoperative radiotherapy group, respectively (p = 0.0265). Chen et al.Cancer staging systems aim to predict survival and then provide information for the selection of therapeutic strategies. The high incidence of regional recurrence of EC suggests that surgery alone is not effective enough in such cases and adjuvant therapy is indicative. However, up to now, whether postoperative radiotherapy and chemotherapy affect the therapeutic outcomes remains controversial.et al.Ando The weakness of this study can be summarized as follows: First, only patients with squamous cell carcinoma were recruited in this study. In contrast, the incidence of adenocarcinoma is dramatically increasing in Western countries. Therefore, the results of this study may be not generalized to be applied in North American and European patients. In addition, on univariate and multivariate analysis, male gender and increased number of positive lymph nodes were significantly associated with worse outcome , 5. Howeth edition of AJCC/UICC TNM classification system are an independent prognostic factor in lymph node positive patients with thoracic EC in a Chinese population. However, the evidence is not powerful enough to support that the new N classification system can help the decision-making for postoperative adjuvant therapeutic strategy in these patients.In summary, the results of our study demonstrate that the new N-category in the 7


Myocardial ischemia is often associated to aortic valve stenosis in the elderly. Aim of this study was to evaluate the impact on survival and quality of life of CABG associated to aortic valve replacement in the septuagenarians and octogenarians.Between January 1991 and January 2010, 520 patients ageing > 70 years underwent aortic valve replacement with a mechanical prosthesis in two Institutions. They were divided into 2 groups: Group A included 406 patients undergoing isolated aortic valve replacement; Group B 114 patients receiving aortic valve replacement and CABG. A comparative analysis of long-term survival and quality of life (SF-36 test) was performed.p = 0.33). Hospital mortality was 9.5% (46 patients). Twenty-nine (7.8%) in Group A and 17 in Group B (15.2%)(p = 0.019). Actuarial survival was 88.5% ± 0.015 at 1 year, 81.9% ± 0.02 at 5 years, 76.6% ± 0.032 at 10 and 57.3 ± 0.1 at 15 years. Ten-year survival was 77% ± 0.034 in Group A and 77.8% ± 0.045 in Group B (p = 0.2). Multivariate analysis did not reveal associated CABG as a predictor of long term mortality. The scores obtained in the SF-36 test were similar in the two groups and significantly higher than those of the general population matched for country, age and sex .Mean age was 74.2 ± 3.6 years (74.3 ± 3.6 in Group A, 74 ± 3.3 in Group B; Associated CABG determines a significant increase of hospital mortality in the elderly undergoing aortic valve replacement. Survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG. Aortic valve replacement (AVR) is an accepted therapy for septuagenarians or octogenarians affected by aortic valve disease . It has Our Institutions Ethics Committee approved this study and waived the need to obtain patient consent. Between January 1991 and January 2010, 520 patients older than 70 years underwent consecutive AVR with mechanical bileaflet prostheses; by policy, mechanical devices were preferred at our Institutions in those years even in elderly patients unless life-long anticoagulation was contraindicated. In our previous studies, the incidence of anticoagulation-related complications was very low in patients older than 70 years, who underwent mechanical prosthetic implant and whose dicumarol therapy was strictly followed at our dedicated outpatient clinic -5.In the light of our experience with mechanical valve implantation and with the management of oral anticoagulation in septuagenarians and octogenarians, associated to high long-term survival rates in those series showed, we prefer the use of bileaflet prostheses in elderly, with the aim to avoid the risk of a possible reoperation in the eight and ninth decade of life for structural degeneration of bioprosthesis.The study population was divided in group A (406 isolated AVR) and Group B (114 CABG associated to AVR).All patients underwent preoperative full cardiological screening including trans-thoracic or trans-oesophageal echocardiography and coronary angiography. All operations were performed by the same group of surgeons. Cardiopulmonary bypass methods were uniform throughout the study: systemic moderate hypothermia was employed in all cases, along with myocardial protection through crystalloid hyperkaliemic cardioplegia infusion into the aortic root in case of normal aortic valve competence, or directly into the coronary ostia in case of aortic valve regurgitation, associated to topical cooling with cold saline.Postoperative anticoagulant therapy was performed with oral sodium warfarin in all patients, and INR was routinely checked daily during the postoperative hospital stay period, then weekly through the first postoperative month, and subsequently on indication of our dedicated anticoagulation outpatient clinic (by default once every three or four weeks). For patients with bileaflet mechanical prostheses in aortic position the target INR ranged between 2.0 and 3.0 before 2000, and between 1.8 and 2.5 thereafter.The method of follow-up for our retrospective studies, in patients wearing mechanical valve prostheses has been described in previous reports (2-5). Follow-up has mainly been conducted on all hospital survivors during our institutional ambulatory activities and was 98.3% complete. Adverse events, with particular focus on bleeding, transient ischemic attacks, reversible or non-reversible ischemic neurologic deficits, are classified following the Guidelines for Reporting Morbidity and Mortality After Cardiac Valvular Operations as proposed by the Society of Thoracic Surgeons . When apTo the purpose of the present analysis, data regarding the operation and the early postoperative period were retrospectively collected by hospital charts and outpatient charts review, while follow-up data of hospital survivors derived mainly from our ambulatorial activities. The anticoagulation results, the data regarding every complication possibly occurred and the scores obtained at the SF-36 test for each patient were retrospectively inserted in an electronic database. INR variability  was calculated for each patient. All patients had been seen at our outpatient clinic and/or followed-up by telephone interview at least once since their discharge. In particular, of the 438 hospital survivors, 328 (74.8%) used to perform periodic controls at our ambulatory  and by June 2010 had already undergone a recent visit (within the last 2 months). Of the other 110 patients , 84.6% were contacted by telephone and then visited in our outpatient clinic to update their follow-up. Thus, all in all, 318 hospital survivors were visited between April and June 2010 .Follow-up included the assessment of perceived QOL through the SF-36 , which h• Physical Functioning (10 items) indicates level of limitations in lifting, bending, kneeling, or walking moderate distance.• Role-physical (4 items) measures the degree in performing of usual activities for age and social status, such as job and community activities.• Bodily Pain (2 items) represents the intensity, frequency, and duration of bodily pain and limitations in normal activities due to pain.• General Health (6 items) is a measurement of perceived overall health, including past and present health.• Vitality (4 items) measures feeling of energy, fatigue, and tiredness.• Social Functioning (2 items) indicates ability to develop and maintain mature social relationships.• Role-emotional (3 items) measures personal feeling of job performance at work or other activities.• Mental Health (5 items) measures the emotional, cognitive, and intellectual status of the patient.All SF-36 domains are scaled from 0 to 100 points, with higher scores indicating better-perceived QOL. The mean scores obtained by the two study groups were compared with those of the general Italian population matched for age and sex.t test. Discrete variables were compared using the chi-square test. Factors significantly associated with adverse outcomes were introduced in a multivariate logistic regression model to identify independent predictors of hospital and long-term mortality. Kaplan-Meier actuarial analyses of survival rates and of freedom from valve-related complications were performed. Scores obtained in each of the 8 domains of the SF-36 test were compared with those reported [p value of < 0.05 was considered statistically significant. SPSS statistical software, version 13.0 was employed for analysis.Continuous data were expressed as mean ± SD, and compared using Student's Kaplan-Meier actuarial analyses of survival rates and incidence of valve-related complications were performed..Actuarial rates are expressed as percentage of patients who were event free.Continuous data are reported as mean ± SD. All statistical analyses were performed with SPSS version 13.0Preoperative characteristics of the study population are reported in Table All patients were older than 70 years with a mean age of 74.2 ± 3.6, 74.3 ± 3.6 in group A versus 74 ± 3.3 in group B (p = 0.33).At time of surgery 47 patients  were in New York Heart Association functional class IV, 338 (65%) were in class III, the remaining 135  were in class II. No difference was evident in proportion of NYHA class comparing the two groups of study population.In-hospital death occurred in 46 patients (9.5%), 29 (7.8%) patients in group A and 17 (15.2%) in group B (p = 0.019) with statistical difference at univariate analisys (p = 0.027). Multivariate analysis on the contrary did not reveal associated CABG as a predictor of hospital mortality. The causes of death were perioperative acute myocardial infarction in 9 cases (19.6%), low output syndrome in 5 patients (10.9%), stroke in 2 (4.3%), pulmonary infection in 16 (34.8%), multi-organ failure in 10 (21.8%), malignant arrhythmia in 2 (4.3%), visceral ischemia in 2 (4.3%).Mean follow-up was 4.2 ± 3.3 years (median 3.2 years) and ranged from 6 months to 17.7 years (2016.95 pts/years). During the follow-up time, 36 late deaths occurred . Causes of death in the follow-up were sudden death in 4 patients, myocardial infarction in 1, intracranial hemorrhage in 1, ischemic stroke in 1, neoplasm in 9, respiratory failure in 8, cirrhosis in 3, dementia in 2, postoperative death (after re-operation for prosthetic endocarditis) in 1, oldness and progressive general delay in 6. Overall actuarial survival  was 88.5% ± 0.015 at 1 year, 81.9% ± 0.02 at 5 years, 76.6% ± 0.032 at 10 years. Ten-year survival was 77% ± 0.034 in Group A, 77.8% ± 0.045 in Group B (log rank = 0.2). A multivariate analysis for long-term mortality did not reveal that associated CABG was a predictor. Dialysis-dependent renal failure was found as predictor of long term mortality .During the follow-up period, the mean INR in this series was 2.15 ± 0.16. Four major hemorrhagic events occurred in 4 patients in the follow-up, including 2 cases of gastric bleeding (requiring surgery in 1 cases), 1 intracranial bleeding and 1 hematuria requiring hospitalization. Freedom from bleeding was 99.7% ± 0.003 at 1 year, 98.4% ± 0.008 at 5 and 96.9% ± 0.013 at 10 years. Thromboembolic complications were observed in 3 patients: 1 ischemic stroke, 1 transient ischemic attack, 1 pulmonary embolism. Freedom from thromboembolism was 99.7% ± 0.003 at 1 year, 99% ± 0.006 at 5 years and 10 years.p = 0.26).Freedom from valve-related complications was 99.1% ± 0.005 at 1 years, 95.5% ± 0.013 at 5 and 94.7% ± 0.015 at 10 years. Ten-years freedom from valve-related complication in the two subgroups did not show significant difference  and univariate analysis revealed CABG as a predictor of early death.At the same time CABG associated to AVR improves long term survival with acceptable morbidity and mortality in elderly patients .This data is confirmed by several reports: on the arena of long term survival, Akins et al. Reported the survival of patient following CABG is essentially equivalent to that of age and gender matched cohorts from the general population up to 5 years after surgery . SergeanFindings of our study confirmed that long term mortality and morbidity are not significantly different when CABG is associated to AVR in elderly patients suffering of severe calcified aortic valve stenosis and obstructive coronary disease.In order to extend the investigation to long term quality of life, the SF-36 test was applied in both groups of patients. Group A and Group B showed similar scores in QOL that resulted better of age and gender matched population. The increased life expectancy results in a growing necessity to maintain maximum functioning and independent lifestyle. Health-related QOL is a multidimensional concept based on the patient's perception of his or her health and integrates not only physical functioning but also psychologic status and social dimensions. Standardized questionnaires, especially those self-completed by patients, are a practical, efficacious, and inexpensive method of collecting data. There is a growing interest in the use of health status to evaluate clinical strategies, and because improvement in QOL is considered to be one of the principal goals of valve surgery , methodsInvestigators focusing on long-term outcomes after AVR in octogenarians have reported a positive impact on QOL . Sundt aWhen interpreting this result, it should be considered that more than 70% of the patients in our study population were in NYHA functional class III to IV before the operation, so a high percentage of our patients experienced, for a various period of time, a moderate to severe limitation to their daily activity. Symptom relief and the return to previous lifestyle can probably increase the perception of a patient's own health status. Similarly, the Italian general population scores were lower than in our study population because the healthy elderly are prone to compare their current physical and psychologic performances with their youth, with a perceived difference caused by the effects of the aging process itself. Other authors in series of AVR  found siAssociated CABG determines an increase of hospital mortality in the elderly undergoing aortic valve replacement; at the same time survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG.The authors declare that they have no competing interests.MV has ideated the research and has written the manuscript, while MDF and SG have conducted the clinical follow-up. RP has interrogated all patients about the quality of life questionnaire. MC and GN have performed surgical interventions. All authors read and approved the final manuscript.


The interval between the onset of Barrett's oesophagus (BO) and oesophageal adenocarcinoma (OAC) can be termed the incubation period. However, the unrecorded onset of BO precludes its direct observation.Determining the range of intervals between BO diagnosis and OAC within the longest observational BO follow-up study. Exclusion criteria were presence of high-grade dysplasia (HGD) or OAC at baseline, death within <2 years of BO diagnosis, oesophagectomy without HGD/OAC and loss to follow-up. A total of 133 patients (M/F 73/60) were taken into account.vs 61.2 and 67.4 years, P<0.001). Baseline presence of low-grade dysplasia was associated with progression to HGD/OAC (log rank P<0.001).In 1967 person years of follow-up there were 13 cases of HGD/OAC, , 96 patients died without HGD/OAC and 24 survived without HGD/OAC. The mean intervals between BO diagnosis and either HGD/OAC, death or end of follow-up were 10.8, 12.6 and 25.5 years, respectively, and the mean ages at endpoint were 72.5, 80.0 and 68.3 years, respectively. The survivors without HGD/OAC had a lower age at BO diagnosis (mean 42.8 The Rotterdam BO follow-up cohort revealed a long incubation period between onset of BO and development of HGD/OAC, in patients without HGD/OAC at baseline as illustrated by 24 patients diagnosed with BO at a young age and followed for a mean period of 25.5 years. Their tumour-free survival established a minimum incubation period, suggesting a true incubation period of three decades or more. Oesophageal cancer is currently the sixth leading cause of cancer-related death worldwide. Since the 1980s the incidence of oesophageal cancer has been rising by about 4–10% annually. . In the The reported wide ranges of observed intervals between BO diagnosis and incident OAC may either be due to large individual differences in progression rates or to large differences in the stage of diagnoses of BO. As practically no reliable long-term predictors of malignant progression have been identified, there is usually no indication at diagnosis which BO patients will survive to incident OAC .There is by definition an interval between the onset of BO and incident OAC, which we will term the incubation period. In 1992 Cameron and Lomboy estimated that BO developed at a mean age of 40 years, whereas the mean age at OAC diagnosis was 64 years. They concluded from this observation that the average incubation period from BO to OAC was more than 20 years . A matheIt is therefore impossible to do more than estimate a minimal incubation period. This might be achieved by examining the length of the intervals between BO diagnosis and incident OAC in very large BO follow-up cohorts and wait until all patients had either developed OAC or died from unrelated causes. However, such cohorts are as yet non-existent. In the current study we have now employed the Rotterdam BO follow-up cohort as the best available alternative. This cohort originally comprised of 166 patients with long-segment BO and has now been followed-up for over 30 years. We updated the outcomes of this cohort 14 years after the previous complete assessment in 1994 , incident HGD/OAC and survival without HGD/OAC. The periods between BO diagnosis and event (BPE) were calculated by outcome group and sex.χ2-test, Fisher's exact test or the Student's t-test where appropriate. Analysis of the time schedule of incidence of HGD/OAC was performed with the Kaplan–Meier survival analysis, testing for statistical significance with the log-rank test and the Cox regression model. All statistical analyses were performed with SPSS . Two-sided P-values below 0.05 were considered significant.The ages at BO diagnosis, length of BPE and age at event were calculated for the three outcome groups and statistically compared with the n=2), death within 2 years of BO diagnosis (n=19), oesophagectomy without HGD/OAC  and loss to follow-up (n=11)  . The remp (n=11) .vs 68.3 years; P<0.001). They also had significantly longer BO segments  and a longer BPE .The males in the cohort were significantly younger at BO diagnosis than females (57.4 years Thirteen patients (M/F 10/3) developed HGD or OAC during follow-up. These were all symptomatic cases of HGD/OAC as the patients were not under endoscopic surveillance and were only reinvestigated for symptoms. These cases were observed over a period of 1967 patient years, 1 per 151 years of follow-up or 0.66 per annum (95% CI 0.58–0.74). Eight patients (M/F 6/2) underwent oesophagectomy, with three postoperative deaths and a mean survival of 8.9 years (range 4.4–15.5) in the survivors. Mean survival in five unoperated patients was 1 year, with two patients dying of OAC and three of co-morbidity. Eventually, in six cases (4.5%) the cause of death was related to HGD/OAC . Two patients who developed HGD/OAC were alive in 2008, their intervals between BO diagnosis and HGD/OAC diagnosis amounted 19.2 and 20.4 years and their current survival post-oesophagectomy was 3.7 and 12.1 years, respectively .vs 70.7 years in females (P<0.001), the male BPE was 12.7 vs 12.6 years in females and the ages at event were 76.2 vs 83.2 years (P<0.0001), respectively (Ninety-six patients (72% M/F 44/52) died without HGD/OAC after an average BPE of 12.6 years (range 2.1–26.8). Their mean age at BO diagnosis was 67.4 years (range 29.6–92.3) and the mean age at death was 80.0 years (range 35–100). The mean age at which the males had been diagnosed with BO was 63.5 ectively .vs 67.4 years in the deceased group; their mean BPE was 25.5 years and the mean age at event was 68.3 years. (P=0.8)  were alive on 1 February 2008 without HGD/OAC. In this group there were no differences by sex in mean ages at BO diagnosis, BPE or mean age at event. However, the differences in all these three parameters with the two previous outcome groups were very significant.  Survivors had an average age at inclusion of 42.8 years  (P=0.8) .vs 69.7 (range 57.2–76.4) years, but the mean male BPE of 12.2 years (range 3.8–20.4) was far longer than the 6 years in females (range 1.6–10.4)  whereas the mean ages at end point were similar 75.6 (range 58.8–86.5) vs 71.5 years (range 56.4–88.7)  than females developed HGD or OAC. The mean age at BO diagnosis was lower in males, 58.7 (range 37.2–77.8) .4–88.7) .P=0.04)  .vs 6.1 cm (P=0.001) (Twenty-seven (20%) patients were diagnosed with LGD at inclusion. In the absence of endoscopic surveillance until 2001, no data were available about new cases of LGD developing before 2001, in practice no cases were observed after 2001. There were no differences in age at BO diagnosis or follow-up interval between patients with and without LGD at inclusion. However, the length of the BO segment at diagnosis was significantly longer in the patients with LGD, 8.3 P=0.001) .P<0.001) (P=0.04) (8.3 vs 6.3 cm); however, using a Cox-regression model the only factor significantly associated with progression was the presence of LGD at inclusion (P=0.004).The baseline presence of LGD was associated with progression to HGD/OAC (Log rank P<0.001) ; 26% of P<0.001) . A BO leThe Rotterdam BO cohort, ranging back to 1973, is to our knowledge the longest running observational cohort of long-segment BO patients. The follow-up results of this cohort were previously published in 1989 and 1996 . This isIn our search for the incubation period from BO to HGD/OAC we in particular focused on patients who were diagnosed with BO at a young age. This study revealed the important finding that there is a long incubation period between onset of BO and development of HGD/OAC, as we have demonstrated in In view of the real date of the onset of BO being unknown, this incubation period is very likely to be in excess of the three decades now observed. The further follow-up of our survivor group will probably extend this observed incubation period even further. The concept of an incubation period is also compatible with the findings in the outcome group of subjects who died without HGD/OAC. The incidence of BO is age related, probably reaching its maximum after age 50 in males and 70 in females .In our cohort we demonstrated that LGD at inclusion is a clear risk factor for progression to HGD and eventually adenocarcinoma. However the issues of inter and intraobserver variability of dysplasia in Barrett's epithelium have been reported by several studies , not dissimilar from the 0.59/100 patient years and 0.56/100 patient years OAC incidence observed in the two previous studies, in which all cases later reclassified as HGD were scored as OAC , now spanning over 30 years, produced HGD/OAC incidences consistent with the two previous surveys. However, the most relevant finding was the length of the interval between BO diagnosis and the end of follow-up in the survivors without the occurrence of HGD/OAC. In these survivors, in whom BO was diagnosed at a 20 year earlier mean age than in the rest of the cohort, this interval amounted to a mean of 25.5 years, with three individuals exceeding 30 years. We interpret this observation as indicating an incubation period between the onset of BO and incident OAC of three or more decades. The combination of the age-specific incidence of BO and such a protracted incubation period may well explain why the great majority of BO patients do not contract OAC.


Normal morphological features of the maternal pelvis are an important prerequisite to vaginal delivery.We aimed to evaluate the association between obstetric conjugate diameter (OCD) measured by ultrasonography and the type of delivery, vaginally (V) or by cesarean (C) section.Pelvimetry was performed in 200 primigravid women for fetal cephalic presentation. The OCD was measured twice by transabdominal ultrasonography during 25-30 weeks and 30-35 weeks of pregnancy.The mean OCD of both sonographies in groups V and C was 125.51± 8.35 mm (105-144.5) and 112.99 ± 8.53 mm (96-134.5), respectively, which was significantly lower in group C (P<0.001). The values of OCD between the first and second measurements were not different significantly (P=0.065). C-section was indicated in 65 (32.5%) mothers. The optimal cut-off point for the OCD in the prediction of vaginal delivery was ≥ 119.75 mm, with a sensitivity and specificity of 80% and 78.5%, respectively.The US measurement of OCD might be an accurate method that almost always remains constant during late pregnancy; it is easy to measure and might be confidentially employed for predicting C-section, but needs more precise studies to be used widely. Cesarean is a word usually used in midwifery to describe live embryo parturition through laparotomy and hysterotomy. Cesarean progressively increased in USA from 1965 to 1988 . MeanwhiOur study aims to measure OCD by transabdominal sonography during late pregnancy and assessing its association with the type of parturition in Iranian mothers.In this descriptive study, 200 pregnant women without a previous problem in the third quarter of pregnancy who were experiencing their first gestation were studied. A transabdominal US scan was done using GE Logiq Alpha 200/ Logiq 200 PRO, US machine  with a 3.5 MHz curvilinear probe. The internal end of the superior periphery of the pubic bone to the sacral promontory was measured as the OCD  A and B The mean age of the studied mothers was 24.12±4.94 years (15-40) . On the There was no significant difference in OCD between the two measurements or during pregnancy in this study (P>0.05). Moreover, Gottlicher et al. (5) demonstrated that no substantial clinically significant increase of the OCD can be found during pregnancy and in repeated pregnancy. We used the mean size of both measured as sonographic OCD value. This value was significantly less in the cesarean group compared with the vaginally delivered group (112.99±8.53 versus 125.51±8.35). Our results are consistent with the study conducted by Adadevoh et al. (7) in which the mean OCD in a group that needed cesarean was significantly less than those who were delivered vaginally. Considering the optimal cut-off point (OCD≥120 mm), the sensitivity and specificity of this method in predicting vaginal delivery was calculated as 80% and 78.5%, respectively. In this study, 118 women with an OCD greater than 120 mm and 82 with an OCD smaller than 120mm, cesarean was performed in 14 (11.9%) and 51 (62.2%) women, respectively, showing a significantly high number in the second group (P<0.001). In this regard, our results are similar to the study carried out by Katonozako et al. (6). In the current study, all the cases with an OCD smaller than 100 mm necessitated cesarean section; while in the cases with an OCD˂120 mm, vaginal birth was done in 27 cases and in the women with an OCD greater than 120 mm cesarean was required in 14 cases. As mentioned previously, the reasons for cesarean delivery were not specified clearly. Therefore, only in women with an OCD smaller than 100 mm, the necessity for cesarean could be expected strongly. We did not measure the OCD by x-ray due to ethical problems. Meanwhile, the comparative studies indicated the highly significant correlation between US and x-ray measurements for OCD . Measuring OCD by MRI, CT scan or transvaginal sonography have been studied with acceptable results (


Needle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China.A cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days.Of the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased . Ninety percent of IDUs recruited from MDCs had low ability to access NSPs.Increased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China. HIV epidemics usually first emerge in China among people who inject drugs. HIV prevalence among injecting drug users (IDUs) in southwest and northwest China has stabilized at ~20% in the past decade-4, with NSPs have been shown to be a safe and effective means to reduce syringe sharing and subsequent HIV transmission among IDUs in various settings-20. AlthHunan province is located in South China, bordered by Guangdong and Guangxi provinces to the south and Guizhou province to the west. All three adjacent provinces are traditional drug-trafficking provinces with exceptionally high HIV prevalence levels among IDUs. Hunan’sUpon informed consent, participants completed a 30-minute questionnaire through face-to-face interviews; no identifying personal information was collected. The standardized questionnaire included questions related to demographic characteristics and injecting behaviors in the last 30 days Table . In partQuestionnaire data were double-entered and checked in EpiData (v3.0). For analyses, study participants were stratified into groups according to (1) their ability to access NSPs  and 2) their venue of recruitment . The survey was collected confidentially and anonymous with no names and personal information obtained. Verbal and written consent procedures were provided to all participants before the survey, and they had the right to withdraw from the study at any time without penalty.A total of 402 IDUs  participated in this study. Of all participants, 333 were male and 69 were female. Ages ranged between 17 to 56 years (mean 34.6 ± 7.1 years). The majority of respondents was ethnically Han (98.5%), had finished junior high school (84.1%), was currently unemployed (92.5%) and was single/divorced (65.4%) . When stratified by recruitment venues, the proportion (74.8%) of IDUs reporting no more than two injecting episodes per day is significantly higher among community IDUs than those from NSP sites (60.1%) and MDCs (60.3%) . Only 29.0% of high-access IDUs reported having re-used syringes before disposal in the past 30 days, significantly lower than the medium and low-access groups (43.1% and 41.3% respectively) . Pattern of repeated use of syringes did not vary substantially across recruitment venues  IDUs injected and consumed heroin exclusively (97.0%) in the past 30 days. A significantly higher proportion of IDUs in the high-access group (77.3%) reported no more than two injecting episodes per day compared with low (58.8%) and medium-access groups (46.3%) . Among those who shared syringes, an IDU shared on an average of 4.28 ± 6.85 occasions with 2.53 ± 1.98 sharing partners. The average sharing group size is approximately three . Respondents from MDCs had the highest syringe sharing rate (19.5%) 30 days prior to their incarceration in comparison with recruits from community (2.3%) and NSP sites (10.5%) ,36 and tOur study has clearly demonstrated behavioral improvements when the ability to access NSPs increases in China. In addition, NSPs have been shown to be highly cost-effective in both international-40 and CThe authors declare that they have no competing interests.EPFC and LZ performed data analyses and wrote the Method and Result sections of the manuscript. XC, JZ1, JSZ conducted the field study and data collection. JZ2 and JJ participated in study design. LZ and XC wrote the manuscript. DPW assisted with data analyses and was responsible for the supervision of the project. All authors read and approved the final version of the manuscript.


Needlestick injuries (NSIs) pose a serious risk for health care workers (HCWs). The aim of this study was to examine the impact of an education program on HCWs practices to prevent needlestick and sharp injury.A hospital wide pre- and post interventional study was conducted in a cardiosurgical university hospital. In the first period, the baseline data including NSIs rate, occupation, location, time and activities associated with NSIs were collected using an anonymous questionnaire. During the second period (6 months) an education program was organized through four workshops. HCWs completed the pretest questionnaire at the beginning of the first period (before the first training session) and the post test at the end of last session.The questionnaires were answered by 93% of all HCWs in the first period and by 89% at the end of second period. There were 76.1 % female respondents. Their mean age was 38.4 (SD 10.4) with mean total work experience of 15.8 years (SD 10.2). They included 14% physicians, 64% nurses, 3% laboratory technicians, 16% health assistants and 4% of other workers. In the six months before intervention, 13.0% of HCWs had at least one accident. About 40% of HCWs were not vaccinated against hepatitis B. During 6 months of education the NSI rate decreased from 13% to 11.2% (p=0.3). The NSIs because of recapping needles were less often (p=0.04) during the second period. The most frequent location of NSIs was patient’s room (52.5% ca in first and 46% in second period). NSIs significantly decreased during night shift in the second period (p=0.01).Training program should be implemented initially to reduce NSIs.None declared.


The prevalence of diabetic nephropathy and its risk factors have not been studied in a society known to have diabetes epidemic like Saudi Arabia. Using a large data base registry will provide a better understanding and accurate assessment of this chronic complication and its related risk factors.A total of 54,670 patients with type 2 diabetes aged ≥25 years were selected from the Saudi National Diabetes Registry (SNDR) and analyzed for the presence of diabetic nephropathy. The American Diabetes Association (ADA) criterion was used to identify cases with microalbuminuria, macroalbuminuria and end stage renal disease (ESRD) for prevalence estimation and risk factor assessment.The overall prevalence of diabetic nephropathy was 10.8%, divided into 1.2% microalbuminuria, 8.1%macroalbuninuria and 1.5% ESRD. Age and diabetes duration as important risk factors have a strong impact on the prevalence of diabetic nephropathy, ranging from 3.7% in patients aged 25–44 years and a duration of >5 years, to 21.8% in patients ≥65 years with a diabetes duration of ≥15 years. Diabetes duration, retinopathy, neuropathy, hypertension, age >45 years, hyperlipidemia, male gender, smoking, and chronologically, poor glycemic control has a significantly high risk for diabetic nephropathy.The prevalence of diabetic nephropathy is underestimated as a result of a shortage of screening programs. Risk factors related to diabetic nephropathy in this society are similar to other societies. There is thus an urgent need for screening and prevention programs for diabetic nephropathy among the Saudi population. Electronic medical health systems have made chronic diseases like diabetes mellitus easier to monitor and understand through large data base registries. Diabetes Registry is gaining popularity nowadays as a result of its advantages in collecting and characterizing data about the disease for clinical and scientific studies. The prevalence of diabetes is increasing globally as a result of urbanization, human aging and lifestyle changes. Diabetes registries track this disease behavior, and provide a better understanding of its clinical, social, cultural and economic impact. Disease registries not only improve perception of the disease, but help in the health planning and assessment of health care quality. They are considered to be a reliable source of epidemiology data that serve to highlight both morbidity and mortality from such diseases Diabetes prevalence in the Middle Eastern region is considered to be the highest, averaging 10.9%. In 2011, six Middle Eastern countries were listed among the top ten countries with a high prevalence of diabetes for ages 20–79 years, with Saudi Arabia ranking seventh Evidence based medicine shows that diabetes morbidity and mortality are attributed to its chronic complications. According to ADA (2012), Diabetic nephropathy (DN) is a microvascular complication known to be the leading cause of ESRD worldwide, and is associated with increased cardiovascular risk. Epidemiology studies of type 2 diabetic patients show that DN prevalence ranges from 7.6% to 55% Saudi Arabia, known as a society with high type 2 diabetes prevalence, has limited data concerning diabetic nephropathy can be used for better understanding of this chronic complication. A study in 2008 unexpectedly considered DN to be the most prevalent chronic complication among Saudi type 2 diabetic patients, accounting for 32.1%, which could be attributed to the sample selection methodology used http://www.jmir.org/2013/9/e202, and the registry website can be accessed from http://www.diabetes.org.sa. This diabetes national registry is one of the Saudi strategic research projects approved and funded by King Abdulaziz city for science and Technology (KACST), which is the official largest funding body in the kingdom.SNDR, hosting more than 100.000 Saudi diabetic patients, can be the best environment to study DN and its risk factors. It is a specially designed electronic web-based data system which incorporates demographic data, diabetic and social history with clinical and biochemical parameters. This registry includes the presence of chronic complications, namely neuropathy, retinopathy, nephropathy, and vasculopathy, as well as associated diseases like hypertension, hyperlipidemia and thyroid disease. The design and development of a web-based SNDR has already been explained in a previously published paper, available at 2 body surface area. Microalbuminuria is diagnosed when albumin is between 30–299 µg\mg creatinine, and macroalbuminuria when albumin excretion ≥300 µg\mg creatinine. Patients were identified with ESRD if they had GFR <30 ml\min per 1.73 m2 body surface area, or had been diagnosed by their treating physician This is a cross-sectional, randomized observational study, where 67,075 Saudi diabetic patients  were selected from SNDR to assess the presence of diabetic nephropathy after been de-identified. ADA criteria were used to identify diabetes types and DN diagnostic criteria. The selected sample was categorized according to DN classification into microalbuminuria, macroalbuminuria, and ESRD. Nephropathy was excluded if a patient had no proteinuria or albumin excretion <30 µg\mg creatinine and normal glomerular filtration rate (GFR) ≥90 ml\min per 1.73 m2) was used for categorical variables such as gender and smoking status, while t-test was used for continuous variables such as age, duration of diabetes and body measurements, including height, weight, Body Mass Index (BMI), and HbA1c. Odds ratio  and p-value of 0.05 or less were used as a level of significance for assessing the risk factors of diabetic nephropathy. The risk factors of DN were plotted using Graph Pad software.All data were entered into the centralized database via the web application SNDR, and was analyzed using SPSS program version 17.0. Descriptive analyses and frequency tables were performed using this program for all variables. Chi square test  kg and 160.24 (±9.74) cm respectively. Mean diabetes duration was 13.55 (±8.14) years.When comparing patients with and without nephropathy, nephropathic patients were significantly older (63.99 vs 59.41 years) and had longer diabetes duration (18.81 vs. 12.85 years), (p<0.0001). Non-nephropathic patients had significantly higher weight, height and BMI than total nephropathic,  respectively and macralbuminuria patients, (p = 0.006). Microalbuminuria patients had a significantly higher weight than non-nephropathic. Patients with ESRD were significantly lower in weight and BMI when compared with non nephropathic. Mean age was significantly higher in microalbuminuria, macroalbuminuria and ESRD patients, representing 57.83(±11.58), 64.34(±11.87) and 64.29(±11.12) years,  respectively. Diabetes duration was significantly longer in patients with macroalbuminuria and ESRD, but not for patients with microalbuminuria, at 19.40, 19.59 and 13.47 years respectively, .The highest frequency was seen among the 45 to 64 age group in the total sample (52.2%), among non-nephropathic (53.3%) and microalbuminuria (59.9%) patients, but among age group ≥65 years, in total nephropathic (51.2%), macroalbuminuria (53.2%) and ESRD (52.3%) patients.Males had higher frequency in the total sample or nephropathic patients, regardless of the nephropathy types, but the highest in macroalbuminuria and ESRD, with a percentage of 60.2% and 64.3% respectively. When comparing the marital status of nephropathic patients with their non nephropathic counterparts, there was a significantly lower percentage of singles, but a higher percentage of widows among nephropathic patients (2.1% vs 1.5% and 5.2% vs 6.5%), . The presence of diabetes family history was significantly higher among nephropathic and patients with microalbuminuria and macroalbuminuria, (p<0.0001), but not with ESRD patients, (p = 0.866), represented by 43.9%, 49.4%, 45.1%, 36.5% respectively. Smoking was significantly more prevalent among nephropathy patients in general, at 10.9%, and at 13.9% for ESRD patients,  respectively, but not in patients with microalbuminuria or macroalbuminuria.2 had significant differences in the total nephropathic patients, when compared with non-nephropathic patients. The percentage was higher in patients with microalbuminuria in ≥30 kg\m2 BMI patients at 54.4%, and was significantly higher in the two extremes of BMI in macroalbuminuria at 20% for BMI ≤25 and 45.9% for BMI ≥30. This was the same for ESRD patients, where 35.7% for BMI ≤25 and 32.3% for BMI ≥30.Extremes of BMI of ≤25 and ≥30 kg/mPrevalence of neuropathy was significantly higher in nephropathic patients as a whole, accounting for 42.4% and each type, namely microalbuminuria, macroalbuminuria, and ESRD 24%, 48.3%, and 36.7%,  respectively. Retinopathy prevalence was significantly higher among nephropathic patients 48.8% and 23.8%, 60.1% and 41% for microalbuminuria, macroalbuminuria, and ESRD respectively, (p<0.0001).Vasculopathy as ischemic heart disease, cerebrovascular disease or periphrovascular disease was found in 36.6% of nephropathic patients, and was significantly higher in macroalbuminuria, (p<0.0001) and ESRD but not in microalbuminuria. Hypertension prevalence was significantly higher among microalbuminuria, macroalbuminuria and ESRD patients, accounting for 69.4%, 70.7% and 91.7%, (p<0.0001) respectively, with an overall prevalence of 76.2%. Hyperlipidemia prevalence was 48.0% in patients with nephropathy, and significantly higher in microalbuminuria and macroalbuminuria patients 66.75 and 42.1%, (p<0.0001) respectively, but not in patients with an ESRD of 40.9%. 18.9% of patients with nephropathy were using insulin, which is significantly higher than non-nephropathic patients, (p<0.0001). This was true for macroalbuminuria, and ESRD 19.5%, and 16.1%, but significantly lower in patients with microalbuminuria 6.8%. Poor glycemic control, represented by the percentage of patients with HbA1c >8%, showed a significantly higher percentages in nephropathic patients, microalbuninuria, macroalbuminuria and ESRD, representing 60.6%, 61.1%, 59.5% and 63.6% respectively with p value <0.0001.In patients with ESRD, diabetes duration of ≥15 years had the highest significant OR (95% CI) of 12.77 (6.32–25.81), followed by the presence of hypertension with OR (95% CI) of 11.81 (8.54–16.32). Retinopathy, neuropathy and age >45 years were significant risk factors with OR (95% CI) of 3.73 (3.09–4.50), 2.97 (2.45–3.60) and 2.77 (1.79–4.29) respectively. Male gender and Smoking were the least risk factors, although still significant, with an OR (95% CI) of 1.47 (1.22–1.77) and 1.41(1.03–1.92). Poor glycemic control was not a significant risk factor, while both overweight and obesity had significant low risk in ESRD with OR (95% CI) of 0.47 (0.34–0.64) and 0.33 (0.24–0.45) respectively.The study sample used in this study represents the known age and gender distribution seen in Saudi society This is true in the Saudi cross sectional hospital based study, where microalbuminuria was reported to be 41.3% in 1994 Saudi men with type 2 diabetes have a higher prevalence of diabetes nephropathy, as has been observed by similar studies in different communities In this study, men have a higher risk of ESRD, which differs from what has been found by the Denmark and Korean studies. This may be explained by the lower number of male patients The prevalence of ESRD in this cohort is three times that reported by the Thailand Diabetes Registry, where it was 0.47% In comparing this registry with similar registries, BMI was found to be higher among Saudi diabetic nephropathy patients than has been reported in Danish people There is a strong correlation between age and diabetes duration, as seen in other published data The forest plot shows diabetes duration to be the most important risk factor, especially ≥15 years. This was the same finding in different ethnic groups, as shown in Korean, Indian and Taiwanese studies Diabetic retinopathy is a known risk factor for diabetic nephropathy in different ethnic populations, as reported in Taiwanese and Danish studies The RENAAL study showed that dyslipidemia was associated with greater hazards in the development of a renal end point The role of strict control on the progression of diabetic nephropathy is not firmly established We have identified being overweight or obesity as a strong and potentially modifiable risk factor for the development of ESRD, which was the same observation as seen in other studies Our observation shows that Obesity seems to be an important -and potentially preventable- risk factor for ESRD that may be explained by weight loss among case patients, as a consequence of morbidity related to renal failure itself, as also seen by another study In conclusion, diabetic nephropathy is underestimated in the SNDR as being due to lack of screening programs, an observation that is shared by other registries. The current data confirms that the most significant risk factors for diabetic nephropathy in Saudi type 2 diabetic population are diabetes duration, retinopathy, neuropathy, hypertension, age >45 years, hyperlipidemia, smoking, and poor glycemic control chronologically. Risk factors for microalbuminuria and macroalbuminuria are retinopathy, neuropathy, hypertension, hyperlipidemia and obesity, while diabetes duration, age >45 years and male gender are risk factors for macroalbuminuria only. ESRD risk factors are the same except for hyperlipidemia and poor glycemic control. There is an urgent need to launch a screening program for diabetic nephropathy, and to start prevention to protect the kidney in diabetic patients.


Anthropometric measures such as the body mass index (BMI) and waist circumference are widely used as convenient indices of adiposity, yet there are limitations in their estimates of body fat. We aimed to determine the prevalence of obesity using criteria based on the BMI and waist circumference, and to examine the relationship between the BMI and body fat.2; obesity ≥30.0 kg/m2) and waist circumference ; body fat mass was assessed using dual energy X-ray absorptiometry; height and weight were measured and lifestyle factors documented by self-report. According to the BMI, 45.1% (95%CI 42.4–47.9) of men and 30.2% (95%CI 27.4–33.0) of women were overweight and a further 20.2% (95%CI 18.0–22.4) of men and 28.6% (95%CI 25.8–31.3) of women were obese. Using waist circumference, 27.5% (95%CI 25.1–30.0) of men and 23.3% (95%CI 20.8–25.9) of women were overweight, and 29.3% (95%CI 26.9–31.7) of men and 44.1% (95%CI 41.2–47.1) of women, obese. Both criteria indicate that approximately 60% of the population exceeded recommended thresholds for healthy body habitus. There was no consistent pattern apparent between BMI and energy intake. Compared with women, BMI overestimated adiposity in men, whose excess weight was largely attributable to muscular body builds and greater bone mass. BMI also underestimated adiposity in the elderly. Regression models including gender, age and BMI explained 0.825 of the variance in percent body fat.This population-based, cross-sectional study was conducted as part of the Geelong Osteoporosis Study. A random sample of 1,467 men and 1,076 women aged 20–96 years was assessed 2001–2008. Overweight and obesity were identified according to BMI (overweight 25.0–29.9 kg/mAs the BMI does not account for differences in body composition, we suggest that gender- and age-specific thresholds should be considered when the BMI is used to indicate adiposity. As in the US In the nineteenth century, the mathematician and social statistician, Adolphe Quetelet, observed that the weight of the average man was proportional to the square of the height Although the BMI is widely utilised as an anthropometric estimate of general adiposity, the failure to identify differences in body composition and body fat distribution limit its usefulness. In recognition that visceral fat accumulation increases the risk for metabolic disease, waist circumference was promoted as an alternative surrogate measure of obesity In this cross-sectional study of men and women enrolled in the Geelong Osteoporosis Study (GOS), we aimed to describe the prevalence of overweight and obesity in Australian adults according to current criteria based on the BMI and waist circumference. Furthermore, we have investigated the relationship between the BMI and body fat determined by dual energy x-ray absorptiometry (DXA).The Barwon Health Human Research Ethics Committee approved the study. All participants gave written, informed consent.The GOS is a population-based study of adult men and women aged 20 years and over, randomly-selected from the Commonwealth electoral rolls for the Barwon Statistical Division in south-eastern Australia. This region is ideal for epidemiological research because the population is large enough  and suitably diverse to be representative of the nation A sub-group of 1,299 (89%) men and 855 (79%) women had whole body scans using DXA that provided valid data on body fat mass; 167 men and 221 women were excluded from statistical modelling for predicting fat mass and percentage body fat (%BF) from BMI because they were unable to assume the correct position for accurate scanning , had prostheses or implants such as pacemakers, stents or breast augmentation (n = 135) or jewellery that could not be removed (n = 13), or they did not have a whole body DXA scan (n = 52).2, overweight if BMI was in the range 25.0–29.9 kg/m2, and obese if BMI ≥30.0 kg/m22, grade II if BMI 35.0–39.9 kg/m2, and grade III if BMI ≥40.0 kg/m2. Waist circumferences of 94.0–101.9 and ≥102.0 cm for men, and 80.0–87.9 and ≥88.0 cm for women, were used to classify overweight and obesity, respectively Standing height without shoes was measured to the nearest 0.1 cm using a wall-mounted stadiometer; weight was measured to the nearest 0.1 kg using electronic scales; waist  and hip  circumferences were measured in a horizontal plane with a narrow, non-elastic tape measure Dietary intakes, including total energy intake (EI) from food and alcohol, were estimated using a food frequency questionnaire developed by the Cancer Council of Victoria Waist measurements were not obtained for 21 men and 22 women; values were computed using prediction equations based on gender, age and weight and included in prevalence estimates for overweight and obesity based on waist circumference. To determine the prevalence of obesity according to BMI, age-stratified samples of men and women were standardised to national age-profiles . Gender differences in prevalence of obesity based on BMI and waist circumference were determined using age-stratified data; tests of homogeneity across age strata were performed in developing these models. For direct comparison with the AusDiab study, prevalence data for obesity were standardised to the 1998 Australian population aged ≥25 years .Multiple regression techniques were used to determine gender differences in the linear relationships between BMI and body fat mass and second order polynomial relationship between BMI and %BF. Polynomial relationships were centred about the mean to reduce collinearity. In validating the models, interaction terms between exposure variables were considered, to identify effect modifiers; interaction terms were retained in the models if p<0.05. Prediction equations for %BF from BMI were developed taking into account the effects of gender and age, and subsequently lean mass and BMC. Statistical analyses were performed using Stata  and Minitab .Our data indicate that, according to BMI criteria, 1.0% of individuals were underweight. Our data also indicate that 37.5% of individuals were overweight and a further 24.5% were obese; prevalence figures for each gender are listed in 2 and obesity grades I, II and III were pooled to form the BMI ≥30 kg/m2 category. Men and women with BMI <25.0 kg/m2 were younger and taller than those who were overweight and obese. The waist/hip and waist/height ratios both increased across increasing categories of BMI. Waist/hip ratio ≥0.80 was present in all but nine men and in 798 (74.2%) of women.BMI was correlated to other indices of adiposity in both men and women; Pearson's correlation was 0.88 for weight, 0.88 for waist, 0.49 for waist/hip ratio and 0.85 for waist/height in men, and 0.92 for weight, 0.87 for waist, 0.32 for waist/hip ratio and 0.86 for waist/height in women . Gender-specific characteristics of the study population are presented in 2, but this pattern was not evident among women.Data from dietary analyses suggest no consistency in the pattern of total energy intake across BMI categories; however, there was an increase in the proportion of individuals with low EI/BMR (<0.9) with increasing BMI. No association was observed between self-reported alcohol intake and BMI for men, but among women, self-reported alcohol intake decreased with increasing BMI. A smaller proportion of obese men were smokers compared to those who were overweight or for whom BMI <25.0 kg/mAge-specific prevalence of overweight and obesity as defined by BMI criteria are shown for men and women in According to waist circumference, our data indicate that 25.4% of individuals were overweight and a further 36.9% were obese; prevalence figures for each gender are listed in There was exact agreement using BMI and waist circumference criteria for categorising normal, overweight and obese groups for 66.1% men and 67.8% women; agreement to within one category was observed for 99.5% men and 96.4% women. Obesity defined by waist circumference identified a larger proportion of the population than did obesity defined by BMI. Whereas 95.3% of the women and 90.8% of the men who were classed as obese by BMI were also obese by waist circumference, only 60.4% women and 55.5% men who were classed as obese using waist circumference were also obese using BMI.2, the mean predicted body fat mass was 17.7 kg (95%CI 17.5–17.9) for men and 24.0 kg (95%CI 23.7–24.3) for women; for BMI 30.0 kg/m2, the mean predicted body fat mass was 27.2 kg (95%CI 27.0–27.5) for men and 33.5 kg (95%CI 33.2–33.8) for women.A linear relationship was observed between BMI and body fat mass . For any2, the mean predicted %BF was 22.7% (95%CI 22.4–23.0) for men and 36.7% (95%CI 36.4–37.0) for women; for BMI 30.0 kg/m2, the mean predicted %BF was 29.9% (95%CI 29.6–30.2) for men and 44.2% (95%CI 43.8–44.6) for women.Gender was identified as an effect modifier in the second order polynomial relationship between BMI and %BF . Over thAccording to internationally accepted thresholds for BMI, 37.5% of individuals (45.1% of men and 30.2% of women) were overweight and a further 24.5% were obese (20.2% of men and 28.6% of women). Prevalence figures using waist circumference were 25.4% overweight (27.5% of men and 23.3% of women) and 36.9% obese (29.3% of men and 44.1% of women). Both criteria indicated that approximately 60% of the population exceeded the recommended threshold for healthy body habitus. An increase in the proportion of men and women with low EI/BMR was observed with increasing BMI and this could reflect deliberate caloric restriction practised by overweight and obese individuals and/or underreporting of dietary intake that is accentuated with greater BMI Our estimated 24.5% (95%CI 23.4–27.2) prevalence of obesity for the period 2001–2008 suggests an increase since 1999–2000, when the nationwide AusDiab study reported a prevalence of 20.8% (95%CI 18.4–23.1) Determining BMI does not require sophisticated equipment and it is easy to calculate; however, we have highlighted limitations in its use as a measure of adiposity. Gender-specific differences in the relationship between BMI and body fat were largely explained by the greater lean mass associated with a muscular male body build and bone mass. Excess weight-for-height attributable to lean and bone tissue rather than body fat may, in part, account for the observed high prevalence of overweight men according to BMI criteria. We also report an effect of age on %BF that was independent of BMI. Thus, there is a likely underestimation of adiposity by BMI in elderly people for whom there is a loss of lean tissue, particularly skeletal muscle, and bone. An age-related decline in DXA lean mass, particularly in men, has been observed in apparently healthy individuals, in the absence of accompanying weight loss Our reported non-linear relationship between BMI and %BF, but linear relationship between BMI and body fat mass, underscores an earlier observation by Garrow and Webster that the correlation between of BMI with %BF is not as strong as the correlation with body fat mass We recognise several strengths and weaknesses in our study. The age-stratified random sampling technique used to generate our sample is a strength that ensured a good representation of all ages across the adult age spectrum. We acknowledge that prevalence data for obesity may be influenced by incomplete participation in the study and a bias related to body composition cannot be excluded; no body composition data were available for non-participants. The use of a bone densitometer for measuring body fat, lean and bone tissue precludes large individuals as the scanner bed has a safety load limit and the bed dimensions do not accommodate very large bodies. Thus, relationships between BMI and body fat have not included the very obese. Similarly, a frailty bias may have been introduced by excluding individuals with prostheses or pacemaker implants. The sample was essentially white and, as the relationship between body fat and BMI differs by ethnicity In conclusion, we report a high prevalence of overweight and obese men and women in Australia, based on BMI and waist circumference criteria. In the absence of sophisticated imaging technologies such as DXA in most clinical settings, body fat is difficult to measure, supporting a role for using BMI to estimate health risk. However, we have demonstrated that excess body weight-for-height may not necessarily be indicative of excess body fat. Our data support an earlier contention that, to improve estimates of excess body fat, BMI thresholds for defining overweight and obesity should be gender- and age-specific to account for differences in body build in men and women and the effects of age on body composition