Background. Lumbar spinal stenosis (LSS) is a disease with increasing prevalence due to prolongation of average life span. Despite various treatment methods, many limitations remain unsolved. Objective. We are reporting cases of patients who have been treated with Wonli Acupuncture, a method of treating LSS by directly approaching the intervertebral foramen and interlaminar space with acupuncture needles different from those used in original acupuncture. Methods. A total of 82 patients with LSS were treated with Wonli Acupuncture, and out of those, 47 patients without exclusion criteria were selected for the following research. We compared the pretreatment VAS and ODI scores based on 1-year follow-up measurements. Results. The ODI value dropped by 15.3 ± 24.8 on average (from 35.2 ± 19.9 at the baseline to 19.8 ± 20.6 at the reading) (P < 0.01) and the average VAS also dropped by 19.2 ± 37.2 (from 60.7 ± 23.1 at baseline to 41.5 ± 31.9 at the reading) (P < 0.01). Conclusions. Wonli Acupuncture was found to have clinical efficacy for lumbar spinal stenosis. Spinal stenosis is defined as the narrowing of spinal canal due to the surrounding bone and soft tissues which results in physical pressure on the nerve root . This isThe lumbar epidural steroid injection is frequently used for patients with lumbar spinal stenosis –11. But To address these limitations, without using existing therapeutic modalities, a method of using physical tools was developed to remove attached tissues, to reduce pressure on the nerve, and to improve surrounding blood circulation. This is acupotomy. Developed by Zhou Han Zhang of China, acupotomy is advantageous for incision and sublation of attached tissues with its thick needle body and its end resembling a sharp knife . AcupotoHowever, acupotomy can damage tissues in the spinal canal such as nerve and blood vessels due to its sharp end. Therefore, we used a rounded tip with more curvature than original tools of acupotomy. We named this Wonli Acupuncture from one of the nine ancient classical needles. To date, there have been no studies revealing the therapeutic effect of Wonli Acupuncture needle on spinal stenosis. Accordingly, this case study research was designed to reveal the effect of the Wonli Acupuncture procedure on direct exfoliation of synechia around nerves.This retrospective case study was conducted at Seoul Wonkwang Korean Medicine Hospital, Seoul, Korea. The study protocol was approved by the institutional review board (IRB) of Semyung University Hospital  with an assigned number of 1402-01. We followed guidelines of Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA); see Not relieved for at least 3 months by conservative treatments ;gluteal pain;radiating pain;provocative factors:neurogenic claudication induced by walking or positional change;palliative factors:symptomatic relief with forward flexion, sitting, and recumbence.Coagulopathy;bleeding diathesis;abnormal findings by ECG, blood test;acute back and leg pain;history of prior spine surgery;abnormal tendon reflexes;muscle atrophy;spondylolysis and spondylolisthesis;degenerative scoliosis;medical conditions that can affect radicular pain, that is, Lou Gehrig's disease and Parkinson's disease.The diagnosis of patients was based on clinical and radiological findings. Despite clinical definition that relies on anatomical findings, severity of LSS depends primarily on the patient's description of their symptoms and physical examination. Studies have reported a high mismatch between symptoms and radiological findings. Hence, when interventions are considered, correlation between symptoms and radiological findings is required –24. StudA doctor of Korean medicine with 19 years of clinical experience led all procedures while patients received Wonli Acupuncture in an aseptic environment. The pre-/postacupuncture effect was investigated by a different doctor of Korean medicine with 3 years of clinical experience, who did not participate in the procedure.Two outcome measures were selected to evaluate the effectiveness of the treatment: visual analogue score (VAS) and Oswestry disability index (ODI), both measured before and after treatment; see The patients were instructed to lie on a table in the prone positionFor a safe approach, the anatomic point and needle points are marked on the patient's skin with a marker.The skin over the surgical field is prepped with povidone iodide antiseptic solution and alcohol solution twice and covered with a germ-free fabric to secure antiseptic environment. The operator wears surgical gloves, mask, and operating gown to maintain aseptic environment throughout the procedure.Acupuncture needle 1: “Dongbang Dochim,” made by Dongbang acupuncture needle company, is 1 mm in diameter, 105 mm in overall length, 80 mm in length of needle, and 25 mm in length of handle and with a flat blade of 5 mm at the tip see .Acupuncture needle 2: It is 2.5 mm in diameter, 145 mm in overall length, 115 mm in length of needle, and 30 mm in length of handle. The tip is a flat blade 11 mm in length see .Acupuncture needle 3: it is a Z-shaped acupuncture needle, 2 mm in diameter, 255 mm in overall length, 150 mm in length of needle, and 105 mm in length of handle, with a blunt and round tip see .Acupuncture needle 4: it is 2 mm in diameter, 170 mm in overall length, 85 mm in length of needle, and 85 mm in length of handle. 15 mm of the needle tip is streamlined and bent at an approximately 20° angle, with blunt and round tip see .Insert acupuncture needle 1 through point A perpendicular to the skin toward the lumbar zygapophyseal joint. Keep the blade parallel with the articular surface of facet joint and incise the facet joint capsule using acupuncture needle 1. Incise the solidification in/out/up/down of the articular process along the bone surface and then incise the synechia of multifidus muscles and rotator muscles in parallel with the muscle grain direction to stretch the shortened muscle.Use acupuncture needle 2 to penetrate through the epidermis at points A and B to secure the inserting point of acupuncture needles 3 and 4. Incise the epidermis layer only to the depth of 10~15 mm.Holding the handle of acupuncture needle 3 insert it perpendicular to point B to a depth of 10 mm, passing through the epidermis. Then, keeping the angle with the epidermis at 45 degrees, insert the needle vertically to the depth of 8~12 cm toward the intervertebral foramen of the disk level until it reaches the anterior part of superior articular process. After reaching the intervertebral foramen of the spine, exfoliate the synechia of soft tissues in the vicinity of the intervertebral foramen located on the anterior side of the facet joint and inside the pedicle, all along the bone surface see .Insert acupuncture needle 4 perpendicular to point A until it reaches the facet joint and then slowly insert it along the internal part of the surface of facet joint bone. Incise the adhered and thickened ligamentum flavum in the interlaminar space along the bone surface. Repeat this procedure until resistance of the yellow ligaments is resolved, indicated by loose feeling. When the yellow ligaments are exfoliated sufficiently, move further toward the intervertebral foramen to exfoliate the synechia in the spinal canal see .During the research period, the number of stenosis patients of whom we measured ODI and VAS was 82. After a year, we received a total of 61 responses. Among the 61 responders, 14 were excluded. One had Lou Gehrig's disease and others had other spinal deformities such as anterolisthesis, retrusion, and serious scoliosis. A total of 47 stenosis patients met our research criteria; see The average age of patients was 57.9 ± 10.0 . The males numbered 20 (42.6%) and the females numbered 27 (57.4%). The average pain period before therapy was 38.8 ± 77.4 months . Regarding the affected spinal level, L4-L5 was affected for 45 patients (95.7%), L3-L4 27 patients (57.4%), L5-S1 26 (55.3%), L2-L3 15 (31.9%), and L1-L2 4 (8.5%). Nineteen patients (40.4%) had a problem with both segments of the spine, 12 patients (25.5%) with 3 segments, 8 patients (17.0%) with a segment, and 3 patients (6.4%) with 5 segments. Regarding the pain aspect of the patients, 39 patients (83%) had unilateral radiating pain, 6 patients (12.8%) had bilateral radiating pain, and 2 patients (4.3%) had no radiating pain but complained only of lumbago.Twenty-one patients (44.7%) received the Wonli Acupuncture procedure once, 22 patients (46.8%) twice, 3 patients (6.4%) 3 times, and one patient (2.1%) 4 times. No patient suffered from serious or life threatening complications or loss of physical function after the procedure.P < 0.01) and the average VAS also dropped by 19.2 ± 37.2 (from 60.7 ± 23.1 at baseline to 41.5 ± 31.9 at the reading) (P < 0.01).Setting 100 points as full marks for the patients following the Wonli Acupuncture procedure the ODI value dropped by 15.3 ± 24.8 on average (from 35.2 ± 19.9 baseline to 19.8 ± 20.6 at the reading)  tend to harden and thicken, often causing calcification . ExfoliaThickened yellow ligaments can be removed from the vertical lamina by inserting acupuncture needle 4 into the interlaminar space. Once exfoliated, the resistance of the yellow ligaments is hardly felt. When the ligaments are satisfactorily exfoliated, moving the needle from the lamina to the deep inside region of intervertebral foramen exfoliates the spinal canal. With a snap, the conglutinated soft tissue of the nerve and disk is taken off the spinal canal.Likewise, venous congestion can be reduced by securing the spinal canal space. Venous congestion may cause circulatory disturbance and further claudication . When thP < 0.05). Based on these results further researches are expected in the future.When we compared the radiological images of pre- and post-Wonli Acupuncture procedure, we observed increases in the distance between the interbodies in several cases. We collected 26 postprocedure X-ray images of 47 patients with LSS in L4-5. The improvement of distance between L4 and L5 was 6.60 mm ± 2.98 to 7.27 ± 2.78 mm, with an average increase of 0.67 mm  Desquamate the ligaments around facet joint with 1mm thick Acupuncture Needle 1. 2) Make an opening enough for procedure, using Acupuncture Needle 2. 3) Using Acupuncture Needle 3, desquamate the soft tissues conglutinant around the intervertebral foramen. 4) Through interlaminar space, insert the Acupuncture Needle 4 and desquamate the conglutinant and thickened ligamentum flavum.


Maternal infection with cholera may negatively affect pregnancy outcomes. The objective of this research is to systematically review the literature and determine the risk of fetal, neonatal and maternal death associated with cholera during pregnancy.cholera and pregnancy for articles published in any language and at any time before August 2013 to quantitatively summarize estimates of fetal, maternal, and neonatal mortality. 95% confidence intervals (CIs) were calculated for each selected study. Random-effect non-linear logistic regression was used to calculate pooled rates and 95% CIs by time period. Studies from the recent period (1991-2013) were compared with studies from 1969-1990. Relative risk (RR) estimates and 95% CIs were obtained by comparing mortality of selected recent studies with published national normative data from the closest year.Medline, Global Health Library, and Cochrane Library databases were searched using the key terms The meta-analysis included seven studies that together involved 737 pregnant women with cholera from six countries. The pooled fetal death rate for 4 studies during 1991-2013 was 7.9% (95% CIs 5.3-10.4), significantly lower than that of 3 studies from 1969-1990 . There was no difference in fetal death rate by trimester. The pooled neonatal death rate for 1991-2013 studies was 0.8% (95% CIs 0.0-1.6), and 6.4% (95% CIs 0.0-20.8) for 1969-1990. The pooled maternal death rate for 1991-2013 studies was 0.2% (95% CIs 0.0-0.7), and 5.0% (95% CIs 0.0-16.0) for 1969-1990. Compared with published national mortality estimates, the RR for fetal death of 5.8 (95% CIs 2.9-11.3) was calculated for Haiti (2013), 1.8 (95% CIs 0.3-10.4) for Senegal (2007), and 2.6 (95% CIs 0.5-14.9) for Peru (1991); there were no significant differences in the RR for neonatal or maternal death.Results are limited by the inconsistencies found across included studies but suggest that maternal cholera is associated with adverse pregnancy outcomes, particularly fetal death. These findings can inform a research agenda on cholera in pregnancy and guidance for the timely management of pregnant women with cholera. Vibrio cholerae and transmitted through fecally-contaminated water or food, which affects children and adults [th century [Cholera is an acute diarrheal disease caused by the bacterium d adults . Around d adults . If thesd adults . Rapid ad adults , and thed adults . The lin century . The 201 century . The exp century –11. In tcholera and pregnancy. No other search terms were used. Bibliographies of relevant published articles were also searched. For papers not excluded based on title and abstract, studies of any design were included if they satisfied the following inclusion criteria: (i) the study involved pregnant women with cholera, (ii) the number of fetal, neonatal, and maternal deaths linked to cholera was assessed. Full text analysis was limited to studies that met the inclusion criteria.Based on the PRISMA guidelines, a systematic review of the literature was undertaken with a search of Medline, Global Health Library, and Cochrane Library databases for articles published in any language and at any time before August 2013 with the key terms Eligible studies were selected and data abstracted by one of the authors (NTT) and reviewed by another (NS), using a pre-agreed table. Discrepancies were examined together by both authors before reaching consensus. For each study that met inclusion criteria, data were extracted on: the first author’s last name; the year of publication; the year(s) of the cholera outbreak; the country where the study was performed; the number of pregnant women with cholera; fetal deaths ; neonatal deaths (defined as death of liveborn infant within the first 28 days of life); maternal deaths (defined in this instance as death of a woman while pregnant or within 42 days of termination of pregnancy); and key study features, study quality and risks of bias. All data used in this article are derived from published studies and reports. No unit record or individual data were obtained or accessed; only publicly available count data were used in calculations.Rates for fetal, neonatal and maternal mortality were obtained by dividing the deaths by the appropriate number of pregnant women with cholera as the denominator. The denominator for neonatal mortality was the number of women in the third trimester reduced by subtracting fetal deaths (assuming singleton pregnancies). Missing data were excluded from relevant sub-group analyses, such as pregnancies of unknown trimester.χ2 test and non-statistical heterogeneity assessed by the Higgins I2 statistic. Due to statistical heterogeneity, meta-analysed pooled estimates were obtained using random-effect models and because of small number, non-linear logistic regression analysis was employed following expansion of studies into unit record files. Negative CIs were approximated to zero. The meta-analysis was performed by time period (1991–2013 and 1969–1990) based on the reported use of oral rehydration therapy (ORS) in the included studies from 1991 onward. Statistical calculations and analyses were performed in Excel spreadsheets and STATA 11 . Outputs in meta-analyses were double checked by the same person (RT) for internal consistency. There were insufficient studies to plot a frequency distribution to investigate possible publication bias.For each study, 95% confidence intervals (CIs) for rates (or ratios) were calculated using the Poisson distribution because of small numbers and instances of zero deaths. Statistical heterogeneity was assessed using the Risk ratio (RR) estimates were obtained by comparing fetal, neonatal and maternal mortality rates of selected studies (with more than zero deaths), with published national estimates of rates of the closest year where available . UN sources were used for national neonatal and maternal mortality ,13, but From 1,005 potentially relevant publications, seven of these met inclusion criteria. Papers were excluded because they were duplicates, did not address the research question, or did not meet the study inclusion criteria. A flow diagram of study selection is shown in χ2 (p<0.05), and there was minimal non-statistical heterogeneity according to Higgins I2. Further pooled analysis of the 1991–2013 studies did not suggest a difference in risk of fetal death by trimester: first trimester: 6.2%, 95% CIs 0.9–11.4; second trimester: 9.1%, 95% CIs 3.5–14.6; third trimester: 6.7%, 95% CIs 0.7–12.8. When compared with national stillbirth estimates, results indicate an elevated relative risk (RR) of third-trimester fetal death for the cohorts in Haiti (2013) of 5.8 (95% CIs 2.9–11.4 and p<0.0001). Although the RR was elevated in Senegal (2006) at 1.8 (95% CIs 0.3–10.4), the p-value was not significant (p = 0.5295), which was also the case in Peru (1991) with a RR of 2.6 (95% CIs 0.5–14.9 and p = 0.3227). For all four studies of 1991–2013, the RR is 3.83 (95% CIs 2.08–7.05) which is significant at p<0.0001.In 1991–2013, fetal death rates associated with symptomatic maternal cholera ranged from 6.0% (95% CIs 1.9–13.9) in Peru/Saona (1991) to 11.5% (95% CIs 4.2–25.1) in Senegal (2006). In 1969–1990, fetal death rates were around 30%, with 32.8% in Nigeria (95% CIs 20.0–50.6), 33.3% in Pakistan (95% CIs 20.4–51.5), and 30.4% in India (95% CIs 23.0–39.5). Pooled meta-analysed fetal death rates by period displayed a statistically significant difference (p <0.0001) between 1991–2013  and 1969–1990 . Within both the 1991–2013 and 1969–1990 groups of studies, there was no statistical heterogeneity based on χ2 (p<0.05), and the Higgins I2 for non-statistical heterogeneity was correspondingly minimal; whereas for the 1969–1990 studies, there was statistical heterogeneity (χ2 (2df) = 40.3, p<0.001) and considerable non-statistical heterogeneity (Higgins I2 = 95%). When compared with national estimates, there was no increased RR of neonatal death from maternal cholera for the cohorts in Haiti  or Senegal . For all four studies of 1991–2013, the RR is 0.28 (95% CIs 0.10–0.84), which is significant at p = 0.0290.In 1991–2013, the neonatal death rates associated with symptomatic maternal cholera ranged from 0.0% (95% CIs 0.0–4.4) in Peru/Saona (1991) to 2.2% (95% CIs 0.1–10.7) in Senegal (2006). In 1969–1990, it ranged from 0.0% (95% CIs 0.0–6.1) in Nigeria (1990) to 33.6% (95% CIs 24.3–45.3) in India (1969). The pooled neonatal death rate for 1991–2013 was 0.8% (95% CIs 0.0–1.6), and 6.4% (95% CIs 0.0–20.8) for 1969–1990, which is significantly different at p = 0.021. Studies in the 1991–2013 period showed no statistical heterogeneity according to χ2 (p<0.05), and the Higgins I2 for non-statistical heterogeneity was moderate at 59%; whereas for the 1969–1990 studies there was statistical heterogeneity (χ2 (2df) = 26.9, p<0.001) and considerable non-statistical heterogeneity (Higgins I2 = 93%). When compared to national estimates, the RR of maternal death from cholera was 4.5 in Senegal, however, not statistically significant . For all four studies of 1991–2013, the RR is 0.79 (95% CIs 0.14–4.45) which is not significant (p = 0.8114).In 1991–2013, the maternal death rates associated with symptomatic cholera infection were zero in 3 studies: Haiti, 2013 (95% CIs 0.0–1.4), Peru, 1994 (95% CIs 0.0–11.2), and Peru, 1991 (95% CIs 0.0–4.4); and 1.9% (95% CIs 0.1–10.57) in Senegal (2006). In 1969–1990, maternal mortality ranged from 0.0% (95% CIs 0.0–6.15) in Pakistan (1969) to 25.5% (95% CIs 18.8–34.0) in India (1969). Pooled maternal death rate for 1991–2013 was 0.2% (95% CIs 0.0–0.7) and for 1969–1990 5.0% (95% CIs 0.0–16.0), which is statistically different at p = 0.034. Studies in the 1991–2013 period showed no statistical heterogeneity according to From the four articles published during the 1991–2013 period, meta-analysis showed pooled estimates for fetal death of 7.9% , neonatal death of 0.8%, and maternal death of 0.2%. The pooled estimates from the 1959–1990 cohorts were 31.0% for fetal death, 6.4% for neonatal death, and 5.0% for maternal death. When compared to available recent national estimates for fetal, neonatal and maternal mortality, the two most recent studies from Senegal and Haiti suggest that there is an increased relative risk of fetal death of approximately 2 to 6 fold, but no increased relative risk of neonatal or maternal death.V cholerae. Except for the Pakistan cohort, which confirmed cholera cases by cultures, the other studies determined cholera mostly based on clinical signs and symptoms, which is an accepted WHO practice [Several issues should be considered when interpreting these risk estimates. Method of confirmation of pregnancy and estimation of gestational age were not mentioned in most studies, and when mentioned, it was through self-report. This could lead to measurement bias by underestimating the denominator (number of pregnant women), especially those in early first trimester, and result in inaccurate classification of pregnancies per trimester. Within the context of cholera outbreaks, it is assumed that all cases of diarrhea are caused by practice . HoweverComparisons by period shows a significant higher absolute risk of fetal, neonatal and maternal death in 1969–1990 compared with 1991–2013, which is particularly marked for fetal death. This reduction in fetal, maternal and neonatal mortality may be explained by progress in cholera management over the past five decades. This includes not only improvement in standardized clinical protocols for cholera, but also in early warning and preparedness, continuous epidemiologic surveillance, good coordination among operational partners, community engagement, and measures to ensure sustainable safe water, sanitation and hygiene infrastructure, which can all contribute to the effective control of cholera outbreaks . Except Comparison between the third-trimester fetal death estimate from the Haiti cohort, which is the largest to date, and the national stillbirth estimates from 2010 strongly suggest that there was a higher risk of fetal death by almost six times in pregnant women affected by cholera (RR 5.7) compared to normative stillbirth data. Analysis of the Haiti cohort indicated that the strongest risk factors for fetal death were severe maternal dehydration and severe vomiting . The 199The comparison of neonatal deaths in pregnant women with cholera from the Haiti and Senegal studies with their respective national NMR estimates matched by time period do not suggest a significant difference in risk of neonatal death. Although the individual national RRs for neonatal death are non-significant, the pooled RR of 0.28 for all four studies of 1991–2013 is significant at p = 0.0290 because of larger numbers. This suggests that neonatal mortality in pregnant women with cholera is lower than the national average. This may be because these women are under clinical care, including giving birth in hospitals, and thus this medical attention may confer an advantage for their children in the first 28 days. Long-term mortality and morbidity of cholera on children exposed to cholera during gestation was not well documented in the selected studies. Only the Pakistan cohort reported cases of seizures (n = 1) and severe spasticity (n = 2) among the 17 children who returned for follow-up within the first two years . LongituWith regard to maternal death in pregnant women with cholera, the comparison of data from the Haiti and Senegal studies with their respective MMR estimates matched by time period do not suggest a significant difference in risk. There was no maternal death in the published Haiti cohort, while the overall case-fatality rate during the 2010 cholera outbreak in Haiti was 2.2% [Epidemic cholera is a disease of critical importance in many developing countries, as evidenced by the large outbreaks over the past decade . The pooDespite the risk of adverse effects on mother, fetus, and neonate, there are currently no internationally-agreed guidelines and recommendations regarding the treatment of cholera in pregnancy. These meta-analysed estimates of cholera-affected pregnancy outcomes indicate the need to carry out further research on cholera and pregnancy, mobilize resources, and develop strategies to include pregnant women as an at-risk population into all policies, programmes and practices on cholera control.S1 Checklist(PDF)Click here for additional data file.


Introduction. The aim of our study is to assess the need for postoperative antibiotics following simple exodontia and determine its role in minimizing patient discomfort and postoperative complications. Material and Methods. All the patients undergoing simple extractions were grouped into two categories: Group 1, patients receiving antibiotics, and Group 2, patients receiving no antibiotics. Patients were recalled on the sixth day to assess postoperative complications. On recall, patients were evaluated for signs of persistent inflammation and signs of dry socket. Presence of persistent inflammation and/or suppuration on the 6th day was considered as wound infection. Results. A total of 146 patients were included in this study. Out of the total sample, 134 (91.8%) presented with no postoperative complications and 12 (8.2%) had postoperative complications, out of which 11 (7.5%) patients presented with dry socket , 5 (3.4%) in the antibiotic group and 6 (4.1%) in the nonantibiotic group. Only 1 patient (0.7%) was reported with infection of the extraction socket in the nonantibiotic group, whereas no case of infection was found in the antibiotic group. Conclusion. Antibiotics are not required after simple extractions in patients who are not medically comprised nor do they have any role in preventing postoperative complications.  The oral cavity has one of the most diverse spectrums of bacterial flora in the body , 2. WhenA new class of antibiotics has not been discovered since the 1980s. Indiscriminate use of the current generation of antibiotics has led to the propagation of various resistant organisms . It is tPrescription of antibiotics after simple tooth extraction has remained a controversial topic amongst dental academia. Antibiotics are thought to increase postoperative comfort following exodontia by preventing wound infection and therefore pain. Although bacteremia certainly occurs during simple exodontia , it alsoThe current trend in dentistry in the developed world is shifting to the notion that antibiotics are not justified following simple exodontia . HoweverThe aim of our study is to assess the need for postoperative antibiotics following simple exodontia and determining its role in minimizing patient discomfort and postoperative complications.Design. The design is randomized control trial.Setting. The setting is Fatima Dental Hospital.Sample Size. The sample size is 146 {n = 4pq/L2}.Sampling Method. The sampling method used is nonprobability purposive sampling.Purposive Sampling. All patients undergoing simple tooth extractions from April 2015 till August 2015 were recruited in the study.Inclusion Criteria. Inclusion criteria are as follows: (1) both male and female patients; (2) patients aged between 10 and 80 years; (3) patients with a good systemic health; (4) patients undergoing simple extractions; (5) patients undergoing extractions of permanent mandibular and/or maxillary teeth; (6) patients undergoing single extractions; (7) extractions requiring minimal instrumentation.Exclusion Criteria. Exclusion criteria are as follows: (1) patients undergoing surgical extractions; (2) patients with deciduous teeth; (3) patients with impacted mandibular third molars; (4) patients with a debilitating systemic disease; (5) patients undergoing extractions of endodontically treated teeth; (6) patients currently taking antibiotics at the time of extraction or have had antibiotics less than 3 days prior to extraction; (7) patients with habits which are known to be detrimental to oral health such as smoking, pan, chalia, and/or tobacco chewing; (8) patients presenting with an acute abscess; (9) pregnant patients.Data Collection. All patients who fulfilled the inclusion criteria, after approval by the Institutional Ethical Review Committee were included in this study.All extractions were performed in the oral surgery department at Fatima Jinnah Dental Hospital by senior dental surgeons (residents) using the following surgical protocol: regular surgical gloves and masks were worn for every extraction; polythene sheets were used to cover each surgical unit and sodium hypochlorite (5%) was used as a potent disinfectant to clean each unit between patients; no more than 2 cartridges of 1.8 mL 2% lidocaine containing 1 : 100,000 epinephrine were administered using 25/27 gauge needle prior to extraction; inferior alveolar nerve block was used for mandibular molars and premolars and local infiltration was used for mandibular anterior teeth and all maxillary teeth.Extractions were performed with minimal instrumentation using a mucoperiosteal elevator, straight elevator (when required), and forceps. Hemostasis was achieved using a cotton pressure pack. Postoperative instructions were given to every patient, in which the patients were asked to apply pressure on the cotton pack for at least half an hour, were asked to refrain from spitting, rinsing, and sucking, and were also advised to take a soft diet and avoid hot food for at least 24 hours following the extraction.Patients were recalled after five days to assess postoperative complications including inflammation, wound infection, and dry socket. Evaluation of pain was done using a numeric scale in association with illustrations using charts. These charts were given to patients for self-assessment after every 1-, 6-, 12-, 24-, 48-, and 72-hour intervals in which they were asked to rate the degree of pain. On recall, patients were evaluated for signs of persistent inflammation  and signs of dry socket . Presence of persistent inflammation and/or suppuration on the 6th day was considered as wound infection. Group 1: patients receiving antibiotics. Group 2: patients receiving no antibiotics.All the patients undergoing simple extractions were grouped into two major categories:All patients in this group were prescribed amoxicillin with clavulanic acid 625 mg 12 hourly for 5 days along with flurbiprofen 100 mg 8 hourly for 3 days starting 30 minutes after the extraction.All patients in this group were not prescribed antibiotic and were given flurbiprofen 100 mg 8 hourly for 3 days starting 30 minutes after the extraction.Randomization was achieved using the closed envelope technique. In this randomization technique, dental surgeons were given randomly generated prescription regimen within sealed opaque envelopes. After establishing consent, the envelope was opened and the patient was then offered the allocated prescription regimen.Data Analysis. Data was analyzed using SPSS version 21. Chi square test was used to test the p value.Null Hypothesis. Antibiotics do not significantly reduce postoperative complications in young healthy patients following simple tooth extraction.Out of the initial sample of 250 (125 in each group), 146 patients appeared for follow-up appointment, out of which 60 (41.1%) were males and 86 (58.9%) were females. Antibiotic group comprised 68 patients  and nonantibiotic group included 78 patients . See Out of the total sample, 65 were maxillary teeth and 81 mandibular teeth. The mean age of the patients was 38.46 ± 12.81. In males the mean age was 40.88 ± 13.87 and in females the mean age was 36.75 ± 11.79. See The most commonly extracted teeth were mandibular third molars 22.6% (11.6% right mandibular third molars and 11.0% left mandibular third molars) followed by maxillary third molars 15.7% (7.5% right maxillary third molars and 8.2% left maxillary third molars). See In the total sample, the most common reason for extraction was that they were found to be grossly carious 65.5%, followed by periodontitis 11.0% and broken down roots 10.3%. See The mean time taken for extraction was 14.51 minutes ± 9.98.Out of the total sample, 134 (91.8%) presented with no postoperative complications and 12 (8.2%) had postoperative complications, out of which 11 (7.5%) patients presented with dry socket , 5 (3.4%) in the antibiotic group and 6 (4.1%) in the nonantibiotic group. Only 1 patient (0.7%) was reported with infection of the extraction socket in nonantibiotic group, whereas no case of infection was found in the antibiotic group.p = 0.025).Out of the 11 cases of dry socket, interestingly, 10 (90.9%) cases belonged to females, whereas only 1 (9.1%) was found in males. Although there was no relationship between antibiotic use and dry socket see , the ovep = 0.021).Out of the total sample, 10 (6.9%) patients showed at least one adverse effect to the drugs prescribed. Diarrhea was reported by 5 (3.4%) patients, abdominal discomfort by 3 (2.1%) patients, and vomiting by 2 (1.4%) patients. The vast majority of patients, 9 (90.0%), who presented with an adverse effect belonged to the antibiotic group. Only 1 patient from the nonantibiotic group reported an adverse effect (vomiting). See p = 0.471).Out of all the patients who experienced an adverse effect, only 2 out of 10 were males. However, this female predisposition was found to be statistically insignificant  patients presented with a complaint of preoperative pain ranging from very mild to very severe pain. Out of 103 patients, 24 (13 in the nonantibiotic and 11 in the antibiotic group) patients reported postoperative pain ranging from very mild to very severe even after 6 days. The average preoperative pain was 5.26 ± 3.66 in the antibiotic group and 3.64 ± 3.49 in the nonantibiotic group.p = 0.111). See Out of the 11 patients who presented with postoperative dry socket, 10 (90.9%) were patients with dry socket who reported preoperative pain  see . Only onp = 0.515).Interestingly, the mean preoperative pain amongst patients reported to be hypertensive was 6.31 compared with an overall average of 4.42. However, this finding was statistically insignificant  in the present study, this effect was clinically trifling and therefore does not justify the use of antibiotics. The vast majority of dental practitioners in this region routinely prescribe antibiotics as a preventive measure to avoid postoperative complications, namely, pain and infection. This practice must be stopped as the evidence overwhelmingly proves that this is unacceptable and a disservice to not only the patient but also the community at large. The use of a stronger analgesic is a much better option after simple extractions to reduce pain in lieu of antibiotics [The antibiotic group showed a better pain profile than the nonantibiotic group, showing a steeper decline in pain despite having a higher mean preoperative pain (see Figures ibiotics .Antibiotics are not required after simple extractions in patients who are not medically comprised nor do they have any role in preventing postoperative complications. Dental practitioners must show greater responsibility and selectivity when prescribing antibiotics.


The Cockcroft-Gault (CG) equation and the four-variable Modification of Diet in Renal Disease (MDRD) formula are the most commonly used methods to provide estimation of kidney function. The newly developed Mayo Clinic quadratic equation (MCQE) is another alternative. The scope of this study is to investigate the prognostic value of the above algorithms as prediction models for development of acute renal injury (AKI) and early renal dialysis (RD) in cardiac surgery patients during the postoperative ICU stay.A retrospective single-centre study of 528 consecutive patients admitted to the ICU, who underwent elective cardiac surgery under extracorporeal circulation from July 2012 to November 2013. Patients undergoing urgent or emergent surgery were excluded prior to the study. Preoperative estimation of renal function was obtained using CG, MDRD and MCQE equations. The predictive capacity of these formulae was tested and compared in relation to AKI and RD incidence by constructing receiver operating characteristic curves for each of the models.2, 69.03 ± 0.82 ml/minute/1.73 m2 and 75.3 ± 1.18 ml/minute/1.73 m2 respectively. AKI was identified in 75 (14.2%) patients, whereas early RD was necessary in 16 (3%) patients. All of the three variables showed a good predictive value for estimating AKI and RD after cardiac surgery. The area under the curve values for the early RD group was 0.887, 0.867 and 0.804, respectively and for the AKI group was 0.701, 0.651 and 0.691, respectively.The mean age of the cohort was 64.7 ± 0.45 years and the mean value of estimated kidney function from MCQE, MRDR and CG formulae was 83.7 ± 1.03 ml/minute/1.73 mOn the basis of our findings, all of the above algorithms seem to be accurate in predicting AKI and RD incidence in the early ICU postoperative period after elective cardiac surgery. Nevertheless, the MCQE equation more accurately classified individuals compared with MDRD and CG formulae. Our results extend knowledge from previous studies ,2]. Fur. Fur2].


High Intensity Focused Ultrasound (HIFU) is a non-invasive treatment for localized prostate cancer. The purpose of this study was to investigate the safety and effectiveness of HIFU as a monotherapy for the initial treatment of low-risk prostate cancer (PCa) in the United States.An Investigational Device Exemption trial received local IRB approval at thirteen sites in the United States and Canada. Subjects with untreated low-risk localized PCa were recruited and treated with single session monotherapy HIFU without adjuvant TURP or hormone ablation. Repeat HIFU procedures were not permitted. Subjects were followed at 1 and 3 months and every three months thereafter. The primary endpoint was 24 month biochemical freedom from failure (the “Phoenix” definition). Subjects underwent biopsy for cause (rising PSA) or at the end of study (24 months). Adverse events were assessed at each postoperative visit and reported as mild, moderate or severe and related to the device or procedure at 24 months.A total of 135 subjects were prospectively enrolled. Mean age and PSA at treatment (± SD) was 64.1 ± 6.7 years and 4.6 ± 2.4 ng/ml, respectively. The Gleason grade and stage were 6 and T1c for 97% and 81% of subjects, respectively. A PSA nadir < 0.5 ng/ml was achieved in 74.1% of subjects. The primary biochemical endpoint was achieved by 90.5% (95% CI: 85.2% - 95.8%) of subjects. Freedom from positive biopsy was 97/135 (72%) at two years. The erectile dysfunction rate was 38%, urinary incontinence: 3%, urinary retention: 3% and stricture: 1%. No fistulae were observed. Both the local (biopsy) control and the biochemical survival rates are promising following HIFU which was utilized as a single session monotherapy without any adjuvants. The adverse event profile demonstrates promising erectile function preservation and low rates of long term morbidity. These results complement published long term outcomes from Europe, where HIFU is utilized in combination therapy, in repeat treatments, and as salvage treatment. Results from this study show that HIFU appears to be a safe and efficacious primary therapy for localized prostate cancer.


Bilevel non-invasive ventilation (NIV) is an established therapy in chronic obstructive pulmonary disease (COPD) but conflicting evidence exists for its use in patients with pneumonia. Initial arterial pH <7.25 is used as a marker of severity and need for admission to critical care (CC) . We examData were collected retrospectively for a 5-year period from 2008 to 2013 using the Metavision electronic patient record. We identified all patients admitted with ARF treated with bilevel NIV. Patients who received continuous positive airway pressure or had a primary surgical problem were excluded. We recorded primary cause of respiratory failure, arterial blood gas values and mortality.A total of 145 patients were identified. Mean age was 64 and 51% were male. The primary diagnosis was pneumonia in 69 patients and exacerbation of COPD in 57. The overall mortality was 19% on CC and 39% at 1 year. In patients with COPD, infective exacerbations had a higher CC mortality (17%) compared with non-infective (0%). However, by 1 year the mortality was 28% in infective and 29% in non-infective. Patients with pneumonia had a higher mortality on CC (25%) and at 1 year (48%). Patients with an initial pH <7.25 were less likely to survive. The mortality at discharge from CC was 16% (pH ≥7.25) and 26% (pH <7.25) but narrowed to 38% and 39% by 1 year. When subdivided, it was found that patients with infective COPD and pH <7.25 had the lowest 1-year mortality (17%) while those with pneumonia and pH <7.25 had the highest mortality (67%).NIV is used in our unit with comparable success rates to published series ,3. COPD


This study aimed to determine the effect of green tea mouthwash on oral malodor, plaque, and gingival inflammation. Gingivitis subjects who had over 80 parts per billion of volatile sulfur compounds (VSC) in the morning breath were randomly assigned into green tea or placebo mouthwash group. At baseline, VSC, Plaque Index (PI) and Papillary Bleeding Index (PBI) were recorded. Participants were rinsed with the assigned mouthwash, and VSC level was remeasured at 30 minutes and 3 hours postrinsing. For the following 4 weeks, participants were asked to rinse with the assigned mouthwash twice daily. VSC, PI and PBI were remeasured at day 28. It was found that, at 30 minutes and 3 hours postrinsing, VSC was reduced by 36.76% and 33.18% in the green tea group and 19.83% and 9.17% in the placebo group, respectively. At day 28, VSC was reduced by 38.61% in the green tea group and 10.86% in the placebo group. VSC level in the green tea group was significantly different when compared to the placebo. PI and PBI were significantly reduced in both groups. However, no significant difference was found between groups. In conclusion, green tea mouthwash could significantly reduce VSC level in gingivitis subjects after rinsing for 4 weeks. Oral malodor is defined as an unpleasant breath odor whose causes originate from the mouth. This condition is caused mainly by the emanation of volatile sulfur compounds (VSC) especially hydrogen sulfide, methyl mercaptan, and dimethyl sulfide through the mouth air. These foul-smelling compounds are produced through the degradation of sulfur-containing amino acids by anaerobic Gram-negative bacteria. Other odoriferous compounds, for example, indole and cadaverine are also reported to cause oral malodor .Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Tannerella forsythia, and Eubacterium species and spirochetes are known to produce significant amount of VSC [Oral malodor was found to correlate with periodontal disease. Quirynen et al.  found tht of VSC . In addit of VSC .Mechanical cleaning methods including tooth brushing and tongue scraping have been found to reduce oral malodor . HoweverCamellia sinensis, or Green tea, has a wide variety of pharmacological activities [in vitro bactericidal activity against odor-producing, periodontal bacteria, P. gingivalis, and Prevotella spp., with an MIC of 1.0 mg/mL [P. gingivalis to oral epithelial cells at a concentration below 0.25 mg/mL [P. gingivalis [P. intermedia [tivities –13. Greetivities . Catechi.0 mg/mL . Green t25 mg/mL . Catechi25 mg/mL  and cystngivalis . EGCG hatermedia . ImmediaThis study was a double-blinded and placebo-controlled clinical trial. The study design was followed to the American Dental Association guideline for the assessment of efficacy of oral malodor products . The stuGreen tea mouthwash and placebo mouthwash were prepared from the Department of Pharmacology, Faculty of Dentistry, Mahidol University. Green tea mouthwash was a hydroalcoholic brownie solution. It contained green tea extract, propylene glycol, parabens, saccharin, and mint flavor. The green tea extract had more than 80% of total catechins. The placebo mouthwash was a hydroalcoholic brownie solution. It contained the same ingredients but without green tea extracts.Sixty participants were recruited from gingivitis patients at the Faculty of Dentistry, Mahidol University. Those who had at least 20 teeth and had over 80 parts per billion (ppb) of VSC in the mouth air were invited to enroll in the study. Patients were excluded from the study if they had systemic complicating factors or oral mucosal lesions. They were also excluded from the study if they were smokers, were denture wearers, or took an antibiotic 1 month prior to the study. Before entering the study, informed consents were obtained from all participants.Number of participants was calculated according to the level of VSC (primary outcome measure) after using 0.2% chlorhexidine mouthwash or 0.03% triclosan mouthwash . We calcA sample size of at least 25 participants in each group would provide 80% power of detection at a two-sided 5% significance level. Thirty participants were enrolled in each group to compensate for the drop out participants.Screening examination was done between 7.00–8.30 a.m. Patients were asked to refrain from tooth brushing, mouth rinsing, eating, or drinking for at least 2 hours prior to the measurement. They were asked to rinse with water for at least 20 minutes before the measurement to protect dry mouth effect and stop talking for at least 5 minutes. VSC level was measured by portable sulfide monitor  as described by the manufacturer. The measurements were performed 3 times, and the mean levels of VSC were recorded as peak ppb. Only gingivitis patients who had over 80 ppb of VSC were invited to enroll the study.C. sinensis extracts) or the placebo mouthwash group using sealed envelopes. Baseline parameters consisting of VSC level, Plaque Index; PI [After screening examination, participants were stratified according to their VSC level. The participants in each strata were randomly allocated into the green tea mouthwash group  and continued their usual oral hygiene and dietary habits but refrain from rinsing with other mouthwash.At day 14 and day 28, participants were asked to return the bottles of the assigned mouthwash. The remaining content of mouthwash was measured. At day 28, they were also asked to complete the questionnaire regarding xerostomia, burning sensation, and changes in taste perception and received oral examination to determine tooth staining and other signs of mucosal irritation. At the end of the experiment, oral hygiene instruction and oral prophylaxis were given to all participants.t-test was used to analyze the VSC level between baseline and 30 minutes, baseline and 3 hours, as well as baseline and day 28, while Wilcoxon sign rank test was used to analyze PI and PBI between baseline and Day 28. For the comparison between green tea mouthwash group and placebo mouthwash group, t-test was used to compare VSC level, and Mann-Whitney U test was used to compare PI and PBI. The significance level was set at P < 0.05.For the comparison within group, paired Sixty participants completed the study. There was no dropout participant. The green tea mouthwash group comprised of 30 participants (27 women and 3 men) with an age range between 18–55 years (mean age of 27.2 ± 9.1 years). The placebo mouthwash group comprised of 30 participants (27 women and 3 men) with an age range between 19–42 years (mean age of 25.8 ± 7.6 years). During the experimental period, none of them received medical interventions which might influence the outcome of the study. At baseline, VSC, PI, and PBI were not significantly different between groups.P < 0.0005) and 3 hours (P < 0.0005) postrinsing. It appeared that the green tea mouthwash could more effectively reduce VSC level when compared to the placebo mouthwash; however, no significant difference was found between groups at any time points .At baseline, VSC level in the green tea group and the placebo group was 187.7 ± 90.3 ppb (95% CI: 155.4–220 ppb) and 185.3 ± 115.1 ppb (95% CI: 144.1–226.4 ppb), respectively. After one-time usage, VSC level was reduced to 116.6 ± 63.6 ppb (95% CI: 93.8–139.4 ppb) at 30 minutes and 119.6 ± 65.4 ppb (95% CI: 96.2–143 ppb) at 3 hours in the green tea group and 146.2 ± 99.6 ppb (95% CI: 110.6–181.9 ppb) at 30 minutes and 164.6 ± 109.3 ppb (95% CI: 125.5–203.7 ppb) at 3 hours in the placebo group . The redP < 0.0005) and to the placebo group (P = 0.023).At day 28, VSC level was 105.5 ± 66.6 ppb  in the green tea group and 162.4 ± 115.7 ppb  in the placebo group . VSC levP = 0.001) and the placebo mouthwash group (P = 0.001). However, there was no significant difference between groups (P = 0.37).PI in the green tea mouthwash group and the placebo mouthwash group at baseline was 1.29 ± 0.30 (95% CI: 1.18–1.40) and 1.17 ± 0.27 (95% CI: 1.07–1.27), respectively. After day 28, PI was reduced to 0.97 ± 0.24  in the green tea mouthwash group and 1.02 ± 0.25  in the placebo mouthwash group . PI was P = 0.001) and the placebo mouthwash group (P = 0.045). However, there was no significant difference between groups (P = 0.677).PBI in the green tea mouthwash group and the placebo mouthwash group at baseline was 0.85 ± 0.24 (95% CI: 0.76–0.94) and 0.82 ± 0.35 (95% CI: 0.69–0.95), respectively. At day 28, PBI was 0.76 ± 0.25  in the green tea mouthwash group and 0.73 ± 0.29  in the placebo mouthwash group . PBI at The remaining content of the mouthwash was not different at day 14 and day 28 in both groups (data not shown) and thus indirectly indicated good participants' compliance. In this study, tooth staining, oral tissue irritation and desquamation, and burning sensation as well as abnormality in the taste perception after using green tea mouthwash or placebo mouthwash for 4 weeks were not found.The pharmacological activity of green tea has been well documented in the field of dentistry –12. In tP. gingivalis [To assess the effect of green tea mouthwash on VSC level and gingival inflammation, the mouthwash was assigned to use twice daily for 4 weeks in gingivitis subjects. The result showed that VSC level was reduced by 38.61% after using green tea mouthwash for 4 weeks. Green tea mouthwash could significantly reduce VSC level when compared to baseline and to the placebo. The ability of green tea mouthwash in reducing oral malodor may result from an antimicrobial activity of green tea catechins, especially on ngivalis  as well ngivalis .Regarding the effects of green tea mouthwash on plaque level, the reduction of plaque was found in both groups without significant difference between groups at the end of the experiment. This may be explained by the Hawthorne's effect. The reduction of VSC was not associated with the reduction of plaque in this study. Because plaque index used in this study could not detect qualitative difference in plaque, the effect of green tea mouthwash on certain periodontal bacteria needs to be further elucidated.P. gingivalis [The interproximal area of the teeth is the area where plaque accumulation is commonly found. In this study, Papillary Bleeding Index (PBI) which reflected the condition of the interproximal marginal periodontium was used. At day 28, a significant reduction of PBI as compared to baseline was found in both groups. When compared between groups, significant difference in PBI could not be detected. It has been shown that catechins and its derivatives could inhibit tissue breakdown through the proteinase activity of ngivalis , 11. In Carvalho et al.  demonstrOral malodor can be assessed by several methods. Organoleptic assessment  most closely resembled daily situations in which malodor is detected. Due to its uncomfortability, the sulfide monitor was used in this study. Previous work by Rosenberg et al.  reportedAfter using for 4 weeks, green tea mouthwash could significantly reduce VSC level in gingivitis subjects without causing remarkable side effects.


The aim of this study was to identify the association between troponin level and the outcome in patients with acute ischemic stroke.We retrospectively investigated 152 patients admitted to our reanimation ICU for cerebrovascular accident between 1 January 2013 and 31 December 2013. Inclusion criteria were as follows: patients with acute ischemic stroke, measurement of serum troponin level and electrocardiography performed within 24 hours of admission. Not included were patients with intracerebral hemorrhage, no brain imaging or electrocardiography, previous myocardial infarction, stable or unstable angina pectoris before admission, previous coronary angioplasty or coronary bypass surgery.n = 81) with serum troponin level >0.01, and those in group 2 (n = 20) with serum troponin level ≤0.01. For 1-month follow-up results of patients, death had occurred in 50.6% (n = 41) of patients in group 1 and in 25% (n = 5) of patients in group 2. There was a significant positive correlation between the increase in troponin level and death within 1 month . The best cutoff point revealed by the ROC curve of troponin was 0.291 mg/l; at which the sensitivity was 73% and the specificity was 79% when used for prediction of death within 1 month (area = 0.319, CI = 0.214 to 0.423, P = 0.021; Figure Of 152 patients, 51 patients were excluded from the study because of the exclusion criteria. The serum troponin level was elevated in 81 patients. The patients were divided into two groups; patients in group 1 (These results suggest that increased serum troponin level at admission is associated with higher mortality rate. Troponin positivity on admission is an independent prognostic predictor in acute ischemic stroke.


The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones.We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant.We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures  and preoperative CKD  were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors.Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease. Retrograde intrarenal surgery (RIRS), combined with Holmium laser lithotripsy is widely applied for the management of intra-renal stones. For large or multiple stones, RIRS may represent an alternative therapy to percutaneous nephrolithotomy (PNL) even if multiple procedures are often required , 2. It iTo date, no study has evaluated the impact of RIRS on renal function. Nevertheless, in case of RIRS, the flexible ureteroscope is introduced into the upper urinary tract collecting system under water pressure. Irrigation during endoscopy cool the tip of energy-delivering devices and helps to maintain a clear visual field by displacing blood, stone fragments, and cellular debris. However, this leads to prolong renal calices distension. Moreover, delivering laser energy next to or directly onto renal tissue may cause damage to the renal papillae. Thus, one could advocate neither prolonging nor multiplying the surgical procedure to avoid renal function deterioration and to decrease post-operative complications. The type and the time of post-operative ureteral catheterization could also protect from renal dysfunction.The aim of this study was to evaluate renal function and identify factors associated with renal function deterioration or amelioration after RIRS.After approval from an institutional review board, we retrospectively analyzed 163 patients undergoing 205 RIRS for intra-renal stones between January 2010 and June 2013 in an academic department of Urology. All patients with a unique radio-opaque stone were previously treated by at least one procedure of Shock Wave Lithotripsy (SWL) without result. Patients were pre and post-operatively evaluated by computed tomography. All procedures were conducted under sterile urine and verified by a urine culture seven days before the RIRS. Confirmed urinary infection or bacteriurias were systematically treated during at least five days with adapted antibiotherapy. We recorded patient age, gender, body mass index, number of stones, diameter of the largest stone, cumulative stone diameter, and stone composition. The perioperative parameters analyzed were the use of pre-operative stenting, the mean operative time, the use of a UAS , the presence of a post-operative ureteral stent or a JJ-stent, the number of procedures and the mean follow-up. The stone free (SF) status was defined when no residual fragments (<2mm) were seen on a non-contrast enhanced tomography performed 1 to 2 months after the last retrograde flexible ureteroscopy session. We performed another RIRS in case of significant persistent stone (>4mm) on the post-operative tomography. RIRS were performed between 2 and 3 months after the previous procedure.2O through the same channel used for working instruments. If necessary a transient water pressure was carried out using a hand pump. A holmium–YAG laser was used at an energy varying between 0.6 to 0.8 Joules, and at a frequency of 8 to 10 Hertz. A 270μm or 400μm laser fibre was used for delivering laser energy. At the end of the procedure a JJ stent or a ureteral stent was inserted under the assessment of the surgeon.The procedures were performed by 10 different surgeons from the same institution. All procedures were done under general anesthesia in a standard flexible ureteroscopy installation. A 0.035 inch polytetrafluoroethylene coated wire was placed in the upper urinary tract under visual and fluoroscopic control through a rigid cystoscope. A safety wire was routinely used. The use of a UAS  was done under the assessment of the surgeon, as well as its insertion method. When no UAS was used, the flexible ureteroscope  was inserted in a monorail way over the second wire. Normal saline irrigation was performed at a pressure of 60 cm HThe evaluation of the Glomerular Filtration Rate (GFR) was derived from the Modification of Diet in Renal Disease (MDRD) study group equation . The bas2 (stage 5)  which classifies estimated GFR in the following ranges: at least 60, 45 to 59 (stage 3a), 30 to 44 (stage 3b), 15 to 29 (stage 4), and less than 15 mL per minute per 1.73m® version 10.Pair t-test was used for comparisons of GFR before and after RIRS. Independent-sample t-test and chi-square tests were used for comparisons of means and proportions, respectively. Univariate and multivariate regression models were used to assess the influence of different variables on renal function outcomes. Only factors that were significant in univariate analysis were considered for multivariate analysis. All tests were done using SPSS2 in 128 (78.5%) cases. Patients presented 3a, 3b and 4 preoperative CKD stage in 27 (16.6%), 7 (4.3%) and 1 (0.6%) cases, respectively. The mean GFR was 84.30±26.2 mL/min/1.73m2.We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. The mean BMI was 26.2±5.9 cm/kg. Patients presented a GFR greater than 60 mL/min/1.73mMultiple stones were present in 73 patients (44.7%). The mean diameter of the largest stone was 12.9±5.7mm, and the cumulative stone diameter was 15±8.6mm. Stone composition was calcium oxalate monohydrate, calcium oxalate dehydrate, uric acid, carbapatite, and unknown in 56 (34%), 8 (5%), 13 (8%), 27 (16.6%) and 86 (53%) cases, respectively. A pre-operative stent was inserted in 46 (63.8%) cases. The mean operative time was 96.4±40.78 minutes. A ureteral access sheath was used in 144 (88.3%) procedures and a postoperative ureteral JJ stent was left in 115 (70.6%) cases. Multiple procedures were performed in 29 (17.8%) patients 24 (14.7%) patients had two procedures and 5 (3%) patients had 3 procedures). At the end of the follow-up, 121 (74.2%) patients were stone free.Perioperative complications occurred in 16 (9.8%) patients . Patient and stone characteristics are reported in the 2. An acute kidney injury, defined as any GFR less than 15 mL/minute/1.73m2, occurred in one (0.06%) patient and no patients needed dialysis. Significant renal function change occurred in 18 cases (11%) with 13 (7.9%) amelioration and 5 (3%) deterioration.The median GFR after procedure was 89.45 mL/min/1,73m2. There was no significant difference with the preoperative median GFR (p=0.675). A change towards a worse or a better CKD group was observed in 8 (4.9%) and 23 (14.1%) cases, respectively , 8 (4.9%) and 0 (0%) patients presented 3a, 3b and 4 CKD stages, respectively. The median GFR after procedure was 84.9±24.4 mL/ min/1.73mectively .The univariate Cox regression analysis showed only two significant factors for renal deterioration: presence of multiple procedures and pre-existing chronic kidney disease . In multivariate analysis these factors did not remain as predictive  . None ofIn this study, we intended to evaluate the incidence of CKD after RIRS for stone management. A key finding of this study is that RIRS seemed to have a small impact on kidney function and was associated with 14.1% of long-term improvement.Ureteroscopy is recommended by the European Association of Urology guidelines as a first–line treatment for proximal ureteral stones greater than 1 cm, but they do not recommend this procedure as a first-line therapy for intra-renal stones . This isAs we know, the use of pressurized water during RIRS leads to a dilatation of renal cavities. However, the consequences of these high intrarenal pressures have not been studied. What we do know is that excessive renal pressure is the main factor of kidney destruction during acute obstructions. Tubular function is threatened by acute excessive urinary pressure. The renal tubular cells stretched by the hydrostatic pressure leads to a tubular interstitial inflammation with macrophages proliferation and myoblasts accumulation. Alteration of the tubular cells associated with macrophages and myoblasts infiltration lead to the production of cytokines and growth factors which are responsible for renal tubular cell apoptosis. This results in chronic obstructive nephropathy with tubular atrophy and loss of nephrons which are replaced by interstitial fibrosis –13.Concerning evaluation of the GFR, we focused on pre-operative, early post-operative and long-term blood creatinine level measurement. Even if the mean GFR before and after RIRS was not significantly different, we found a trend towards GFR improvement. This can be explained by numerous factors. The true prevalence of obstructive nephropathy is unknown but it is known that nephrolithiasis duration, subsequent urinary tract infections, and size of stones are factors that influence renal function –16. As aIn our study, multiple procedures appear as predicting factors of renal function loss in univariate analysis but did not stay significant in multivariate analysis. This could be explained by the effect of RIRS on the kidney but also by the fact that patients with multiple procedures often have larger stones and more advanced nephrolithiasis disease. Interestingly, operative time was not a predictive factor of renal function loss. In this context, kidney function did not seem to be a good argument for limiting the RIRS procedure time. Moreover, if a UAS is known to decrease intra-renal pressure, we did not find any influence on post-operative renal functional outcomes . The uniConsidering the superior number of patients changing to a better CKD group, we researched predictive factors of renal function improvement but no significant result clearly appears. However, our result confirmed that removal of a stone improves postoperative renal function .To our knowledge, there is no study assessing the renal functional outcomes after flexible ureteroscopy. Nevertheless, this point is essential in the therapeutic decision for the management of kidney stone diseases. PNL is considered as a more invasive procedure and is indicated for larger stone diameters (more than 2 cm). For these larger stones, if RIRS is performed, multiple procedures might be required, whereas usually only a single session is required for PNL. Moreover, PNL is known to have a good functional outcome even on solitary kidneys , 19. A kThere are several limitations to this study. First, this is a retrospective review from a single institution. The results are based on a relatively small sample size and we could not confirm that multiple procedures and preoperative kidney disease were prognostic factors of kidney function deterioration in multivariate analysis. Moreover, there might have been a confusing factor due to the contralateral compensation of the non-treated kidney for all patients with two kidneys. However, a solitary kidney model could have been more informative but it is rare and represents a very different clinical situation. Moreover, kidney function deterioration could also be linked to urolithiasis disease and it is difficult to know the part played by either natural history of the disease or RIRS. Larger cohorts and longer periods of follow-up will be necessary to consolidate these data and to confirm the identified predictive factors.After RIRS, 8 (4.9%) patients had a decrease and 23 (14.1%) patients had an improvement of their renal function. Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.


Deliberate self-poisoning is a common presentation to hospitals, with 13,268 presentations to Scottish hospitals in 2004 accounting for 1.11% of total admissions [[To assess the epidemiology and outcomes of self-poisoning admissions to our local intensive care unit, and to quantify which substances are currently most prevalent.TMsearch was performed retrospectively for all admissions with the primary unit diagnosis equal to 'self-poisoning'. the search returned 330 records . We excluded any records that were alcohol poisoning only, had no record of what substances were taken, or were missing APACHE data (n = 156).A WardWatcherA total of 174 records were included in the analysis. the mean age was 37, and there was a slight propensity for male gender (F:M = 1:1.15). the mean length of stay was 1.8 days, with 39% (n = 68) staying less than one day. the mean APACHE mortality prediction was 15.3%. Actual unit mortality was 2.3% (n = 4), with a standardised mortality ratio (SMR) of 0.15. the most common presentation was that of a mixed overdose in 46.6% (n = 81); the commonest substances taken included anti-depressants in 42.5% (n = 74), paracetamol-containing drugs in 14.9% (n = 26), and benzodiazepines in 21.3% (n = 37). Alcohol was also involved as part of the mixed overdose in 25.2% (n = 44).Our review shows a similar demographic for self-poisoning admissions - patients were under forty and there was a slight propensity for male gender. the actual mortality in our dataset was lower than that reported elsewhere, and significantly the SMR was less than one. the most prevalent substance taken in our review was anti-depressants.


While the prevalence of mental illness or cognitive disability is higher among homeless people than the general population in Western countries, few studies have investigated its prevalence in Japan or other Asian countries. The present study conducted a survey to comprehensively assess prevalence of mental illness, cognitive disability, and their overlap among homeless individuals living in Nagoya, Japan.Participants were 114 homeless individuals. Mental illness was diagnosed based on semi-structured interviews conducted by psychiatrists. The Wechsler Adult Intelligence Scale-III  was used to diagnose intellectual/ cognitive disability.Among all participants, 42.1% (95% CI 33.4–51.3%) were diagnosed with a mental illness: 4.4% (95% CI 1.9–9.9%) with schizophrenia or other psychotic disorder, 17.5% (95% CI 11.6–25.6%) with a mood disorder, 2.6% (95% CI 0.9–7.5%) with an anxiety disorder, 14.0% (95% CI 8.8–21.6%) with a substance-related disorder, and 3.5% (95% CI 1.4–8.8%) with a personality disorder. Additionally, 34.2% (95% CI 26.1–43.3%) demonstrated cognitive disability: 20.2% (95% CI 13.8–28.5%) had mild and 14.0% (95% CI 8.8–21.6%) had moderate or severe disability. The percent overlap between mental illness and cognitive disability was 15.8% (95% CI 10.2–23.6%). Only 39.5% (95% CI 26.1–43.3%) of the participants were considered to have no psychological or cognitive dysfunction. Participants were divided into four groups based on the presence or absence of mental illness and/or cognitive disability. Only individuals with a cognitive disability reported a significant tendency toward not wanting to leave their homeless life.This is the first report showing that the prevalence of mental illness and/or cognitive disability among homeless individuals is much higher than in the general Japanese population. Appropriate support strategies should be devised and executed based on the specificities of an individual’s psychological and cognitive condition. The prevalence of mental illness and/or intellectual/cognitive disability is higher among homeless individuals compared to the general population in Western countries –5. FazelNagoya is the fourth largest urban city in Japan, with approximately 2.3 million people. According to a 2012 report conducted by the Nagoya local government, there were 347 homeless individuals in Nagoya city . The totInformed consent was conducted on 114 homeless adults on November 2, 2014, in Nagoya, Japan. The definition of homeless was taken from the Department of Health and Human Services in the US; Someone who is “homeless” is “an individual who lacks housing without regard to whether the individual is a member of a family, including an individual whose primary residence during the night is a supervised public or private facility  that provides temporary living accommodations, and an individual who is a resident in transitional housing . In the The Ethical Review Committee, Graduate School of Medicine, Gifu University, approved this research protocol on August 6, 2014 . All participants were given detailed face-to-face explanations regarding the protocol by medical professionals and provided written informed consent. This informed consent form was written in manner that made it easy to read (at reading level commensurate with IQ score below 69). Based on interviews and medical records, participants who required medical care or welfare services were referred to the appropriate medical institutions at the time of the survey.In rented, quiet, and separate meeting rooms within an office building located near the Nagoya station, the psychiatric diagnostic interview, the Wechsler Adult Intelligence Scale version III (WAIS-III) , and a sThe 114 participants were divided into four groups according to the following: A, absent a mental/cognitive diagnosis; B, only a cognitive disability; C, only a mental illness; and D, both a cognitive disability and mental illness. Between each of the four groups, the following items were compared: mean age, gender, mean current homeless life length, residence, habitual smoking percentage, habitual drinking percentage. Participants responded to the following Likert scale item  . Analysis of variance (ANOVA) was used to compare age and period of homeless life among the A-D groups. Chi-square tests were used to compare gender, residence, history of smoking, history of drinking, and history of gambling in the A versus B, C, and D groups.Socio-demographic variables from the 114 participants (including 106 men and 8 women) are shown in A mental illness diagnosis by certified psychiatrists, and cognitive disability measured with WAIS-III scores are shown in Mean IQ was 79.2 ± 21.0 (95% CI 83.1–75.3), excluding one participant who had an IQ too low to be measured with the WAIS–III. 34.2% (95% CI 26.1–43.3%) of participants were diagnosed with a cognitive disability, including 20.2% (95% CI 13.8–28.5%) with a mild cognitive disability and 14.0% (95% CI 8.8–21.6%) with a moderate/severe cognitive disability. We also investigated the overlap in mental illness and cognitive disability diagnoses. 15.8% (95% CI 10.2–23.6%) had both a diagnosed mental illness and cognitive disability. Only 39.5% (95% CI 26.1–43.3%) were considered to have neither an cognitive disability nor a diagnosed mental illness.From comparisons between the WAIS-III and JART, 64 participants showed decrements that were larger than a normal range of dissociation (11 points). Since the JART cannot measure IQ scores lower than 69, participants with low IQ values due to developmental issues likely would show a greater dissociation between IQ scores and the JART. Thus, we excluded participants with a JART-estimated IQ score that was within the spectrum of cognitive disability or borderline (IQ < 80). Forty-eight participants met this criterion; 24 that had a diagnosed mental illness , 14 withParticipants were divided into 4 groups according to the presence/absence of an intellectual disability or mental illness, and were analyzed . There wParticipants’ responses to the question are shown in The current study had the following aims: (1) investigate the prevalence of cognitive disability, mental illness, and their overlap in a Japanese homeless sample and; (2) clarify potential differences in needed support among these four sample groups.We have already reported the prevalence of cognitive disability and mental illness in a small sample of Japanese homeless residents . The preCompared to prevalence rates in Western countries reported by Fazel and colleagues , depressThe current study also measured intellectual capacities among this homeless sample; 34.2% presented with a cognitive disability, including 20.2% with mild and 14.0% with moderate to severe disability. Okuda  observedOver the past 20 years 1994–2013), only four previous studies have reported IQ scores obtained from adult homeless samples within Western countries. One was performed with a very young homeless sample between the ages of 16 and 21 years old in the US, observing that 6% of the sample had IQ scores within or at the border of the cognitive disability range IQ < 80) . The sec0 . The s94–2013, The present study also investigated the overlap between mental illness and cognitive disability among homeless individuals. 15.8% of participants were considered to have both a mental illness and cognitive disability. Only 39.4% of participants were absent either a mental illness or cognitive disability. In other words, 60.6% of the present sample had at least one or the other. This high proportion of mental and cognitive difficulties should make it apparent that this segment of the population is in need of intervention. Thus, additional research should provide insight as to the support needed for homeless individuals with mental illness and/or cognitive disability.The present study also assessed rates of habitual smoking, drinking, and gambling. Results showed that rates of habitual smoking and gambling were rather high relative to participants’ rather low incomes. The habitual smoking rate was 71.1% in the present sample, which is much higher than the rate among Japanese men in the general population (34.1%) compiled in 2012 . High smThe present sample was divided into four groups based on the presence or absence of mental illness/cognitive disability. There were no significant differences between groups on several socio-demographic factors, as well as habitual smoking, drinking, and gambling rates. Answers to the question, “Would you like to leave your homeless life?” showed that participants with a cognitive disability were less likely to answer this question in the affirmative. This finding suggests that such individuals may refuse social support and receipt of services due to their cognitive disability. Thus, one’s refusal to eschew their homeless life might not be fully willful; it might be due to an awareness of difficulties related to social adaptation. Thus, homeless individuals with cognitive disabilities should be supported by those who specialize in dealing with social adaptation issues as a way to allay these concerns.This is the first study to examine the prevalence of mental illness, cognitive disability, and the overlap between the two in a Japanese homeless sample. Approximately 60% of the individuals presented with a mental illness, a cognitive disability, or both; this rate is much higher than what is observed in the general Japanese population. To better maximize support systems for the homeless in Japan, an understanding of mental and psychological issues, beyond basic economic concerns, is tantamount to enhancing social welfare within this population.


The Mean platelet volume and platelet counts are indicators of thrombotic potentials, and risk factors for microvascular complications in diabetics. This study aimed to establish variations in platelet counts and mean platelet volume in type 2 diabetic patients on treatment and non-diabetic controls.This was an unmatched case-control study involving 200 participants consisting of 100 diabetics and 100 non-diabetic controls. Four and half milliliters of blood was collected from diabetics and non diabetic controls into EDTA anticoagulant tubes. Full blood count was performed using the Sysmex KN-21N,  a three- part auto analyzer able to run 19 parameters per sample including platelet counts and mean platelet volume.9/L and controls, 211.32±66.44*109/L. The mean platelet volume, for the diabetics was 8.69±0.67 fl and the controls, 8.91±0.80 fl. There was a statistically significant difference in platelet counts of diabetics and healthy controls p =0.038 while none existed between the mean platelet volume in diabetics and healthy controls p = 0.593.The mean fasting blood sugar for the diabetics was 147.85±72.54 mg/dl and the controls 95.20±30.10 mg/dl. The mean platelet count for the diabetics was 235.29±76.81*10This study revealed a higher mean platelet count for diabetics on treatment than for non diabetic controls while mean platelet volume was lower in cases than controls. However, both parameters in diabetics on treatment were within the normal reference range for healthy individuals. Type 2 Diabetes mellitus (DM) accounts for 80% of all DM . An inteStudy Population: This was a case-control study of 100 type 2 diabetic patients on treatment attending the diabetic clinic of Lagos State University Teaching Hospital (LASUTH) and 100 non diabetic controls consisting of medical students, nurses and doctors in the Institution. During the study period between June 2013 to September 2013 all patients who gave informed consent and satisfied the study inclusion criteria were recruited into the study. They were asked to fill structured questionnaires including demographic information, height, weight, last fasting blood sugar, blood pressure, drug history, and family history of diabetes. All the cases were on oral hypoglycaemic and antiplatelet drugs like clopridogel and vasoprin tablets, some were on antihypertensive and lipid lowering drugs. Information on family history of diabetes was also obtained from the controls and they were subjected to fasting blood sugar before enlistment.Ethics: The research was approved by the Ethics Review Committee of LASUTH.Inclusion Criteria for the cases: All non-insulin dependent diabetes mellitus patients on treatment attending the diabetes clinic.Exclusion Criteria for the cases: Non-diabetic patients and insulin-dependent diabetes mellitus patients.Inclusion Criteria for the controls: All consenting non-diabetics adults.Exclusion Criteria for the controls: Diabetics adults on oral hypoglycaemic drugs.Sample Collection: Blood specimen was withdrawn with minimal stasis from the ante-cubital vein using a dry sterile disposable syringe and needle. Four and half milliliters of blood was dispensed into EDTA anticoagulant tubes. The specimens were labeled with subject's age, sex and identification number. The EDTA samples were kept at room temperature until processed within 4hours of collection.Laboratory Analysis: Full blood count was performed using the Sysmex KN-21N,  a three- part auto analyzer able to run 19 parameters per sample including haemoglobin concentration, packed cell volume, red blood cell concentration, mean corpuscular haemoglobin, mean cell volume, mean corpuscular haemoglobin concentration, white blood cells and platelet count and mean platelet volume. Standardization, calibration of instrument and processing of samples were done according to manufacturer's instructions.Procedure: Well mixed blood sample was aspirated, by letting the equipment sampling probe into the blood sample and then pressing the start button. Approx. 20ul of blood was aspirated by the auto analyzer. Result of analysis is displayed after about 30secs. A printout copy of result is released on the thermal printing paper.Statistical Analysis: Data were analyzed using SPSS version 16.0 . The continuous variables were given as means ± standard deviation (SD). The Pearson chi squared test was used to test for association between discrete variables. P value was considered to be statistically significant when < 0.05.2 and 147.85±72.54 mg/dl respectively. For the controls they were 25±5.23 kg/m2 and 95.20±30.10 mg/dl respectively. Amongst the diabetics, a total of 45 of 100 (45%) gave a positive family history of diabetes while 55% had no family history of diabetics. Only 5% of the controls gave a positive family history of diabetics. The mean duration of diabetics in the cases was 8.81±7.06 years. The overall mean platelet count was 223.49 ± 72.71 *109/L, for the diabetics 235.29±76.81*109/L and controls, 211.32±66.44*109/L. The overall mean platelet volume was 8.8±0.74fl, for the diabetics 8.69±0.67 fl and the non diabetic controls 8.91±0.80 fl (A total of 200 participants were enrolled into the study consisting of 100 diabetics and 100 non-diabetic controls. The mean age of the controls was 32.38±66.44 years with a minimum 17 years and a maximum of 70 years. The mean age of diabetics was 62.35 ± 9.84 years, the minimum was 34 years and the maximum 90 years. The overall female: male ratio was 68%:32%, while the gender distribution in diabetics was 73%:27%, for the controls it was 63%:37% respectively . The mea±0.80 fl . There wThe MPV and platelet counts are indicators of thrombotic potential, and risk factors for microvascular complications in diabetics –19. MPV Our finding of a significant positive relationship between the MPV and the duration of diabetes gives credence to the fact that the risk of microvascular complications increases with the duration of diabetes. Discordant results were however found in studies conducted by Thomas et al and Hekimsoy et al. , 17. ThiThis study revealed a higher mean platelet count for diabetics on treatment than for non diabetics controls while mean platelet volume was lower in cases than controls. However, both parameters in diabetics on treatment were within normal reference ranges of healthy individuals.


To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011.We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models.The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births  in 2000 to 66.2 (95% CI: 59.0–74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1–130.7) in 2000 to 76.2 (95% CI: 66.7–86.9) in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08–1.92) higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18 (95% CI: 0.90–1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99–1.47) in 2000–2001 to 1.48 (95% CI: 1.15–1.89) in 2010–2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09–1.55) to 1.15 (95% CI: 0.95–1.39) in the same period.While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities. The sites are largely rural with economies that are dominated by subsistence farming, fishing and petty trading.,The surveillance system collects data in three rural districts in the United Republic of Tanzania. The Rufiji surveillance system is located in Rufiji district in the eastern part of the country while the Ifakara surveillance system is located in Kilombero and Ulanga districts in the south central part of the country. The surveillance sites cover approximately 4200 kmBaseline census data were obtained in September 1996 for the Ifakara surveillance population and in November 1998 for the Rufiji surveillance population. Since then, the data have been updated in 120-day intervals by interviewers revisiting households to register the occurrence of all births, deaths, household migrations and marital status changes. Pregnancies are documented and pregnancy outcomes are solicited in subsequent household visits. In annual cycles, data on socioeconomic indicators are collected such as level of education, occupation and household socioeconomic status measured with proxy markers – such as household possessions, household water and sanitation and building materials.In the beginning of 2011, the total surveillance population was about 190 000 persons (82 012 persons in Rufiji and 108 655 persons in Ifakara), of which 22 981 (12.1%) were younger than 5 years. Major causes of mortality for these children included malaria and fever, pneumonia, prematurity and low birth weight, birth injuries, asphyxia, anaemia and malnutrition.We collected information on all children younger than 5 years living in the surveillance sites between 1 January 2000 and 31 December 2011. Beginning with all children younger than 5 years on 1 January 2000, we added children who entered the surveillance system through birth or migration into the study area. Children were observed until the end of the study period, 31 December 2011, unless they were censored due to death, migration out of the study area or reaching the age of 5 years.Variables included sex of child, birth order , maternal age at birth of child , maternal educational attainment  and household wealth quintile . Time period was included into the analysis as a continuous variable from 2000 to 2011 to account for changes in mortality over time.,We constructed an asset index as a proxy for wealth using the principal components analysis (PCA).Household socioeconomic data were collected each year in Ifakara from 1997. In Rufiji however, data were collected in 2000, 2004 and in every year since 2007. For the years lacking these data, we used the most recent estimate available. This limitation to our data involved the assumption that the most recent assessment of household socioeconomic status was applicable to subsequent periods and therefore, that household socioeconomic status did not change between 2000 and 2002, between 2003 and 2005 and between 2006 and 2007.We did not control for possible confounding factors related to child characteristics, such as birth type (single or multiple), or maternal characteristics, such as marital status changes, presence or absence of household heads or the geographic remoteness of households because these data were only collected from 2003 onwards.The overall trends in under-five mortality for the period 2000–2011 were calculated using Kaplan–Meier analysis.h defines the hazard of childhood death for exact ages in days from t = 0 to 60 months and x defines i indicators of maternal or child characteristics that are unrelated to equity and y defines j indicators of social and economic disparity and z defines time in periods of two calendar years each.A multivariate model of child survival was created to measure the relationship between mortality and maternal, child and household characteristics. This multivariate hazard regression model (model 1) was constructed as follows:P-value of 0.05 was defined as statistically significant. For model 2, because of low statistical power for interaction tests,–To determine whether mortality disparities by wealth quintiles and educational status were changing during the mortality transition, a model was created that assessed for interactions between time and maternal educational attainment and between time and household wealth. This multivariate hazard regression model (model 2) was constructed as follows:Following an explanation of the health and demographic surveillance system, each participant in the surveillance system is asked to provide written informed consent . Local leaders at village and district levels were informed about the survey and the use of data. Respondents remained anonymous. The data collection procedure was reviewed and approved by the ethical review committees of the Ministry of Health and Social Welfare of the United Republic of Tanzania, the National Medical Research Coordination Committee of the National Institute for Medical Research and the Ifakara Health Institute’s Institutional Review Board. We sought authorization for use of data from the Ifakara Health Institute through the Connect project (IHI/IRB/No.16–2010). Ethical clearance for the analysis was accorded by the Columbia University Medical Center Institutional Review Board (Protocol-AAAF3452).During the period 2000–2011, 140 162 children younger than 5 years were resident in study sites, of which 55.7% (78 136) was registered in Ifakara and 44.3% (62 026) in Rufiji. They contributed to a combined 325 960 person-years of observation. Half of the children were boys, (39 034 boys in Ifakara and 30 919 boys in Rufiji). Forty-seven percent (28 861) of mothers in Rufiji and 35.2% (27 472) in Ifakara did not have any formal education. Of the 83 929 mothers who were educated, 14.6% (11 412 in Ifakara and 9074 in Rufiji) had not completed the primary level of education. In Ifakara, 47.8% (37 349) of the mothers had completed the primary level; corresponding percentage was 35.0% (21 689) in Rufiji. Only 2.4% (1903) of mothers in Ifakara and 3.9% (2402) in Rufiji acquired schooling beyond the secondary level. There were 14 828 children living in the poorest quintile of households in Ifakara and 10 256 in Rufiji .The under-five mortality rate, measured as a probability of dying before 5 years of age, declined by 43.4%, from 124.4 deaths per 1000 live births in 2000  to 70.4 in 2011 (95% CI: 64.5–76.7). During this period, the reduction was greater in Ifakara – from 132.7 deaths per 1000 live births (95% CI: 119.3–147.4) to 66.2 (95% CI: 59.0–74.3) – than Rufiji – from 118.4 deaths per 1000 live births (95% CI: 107.1–130.7) to 76.2 (95% CI: 66.7–86.9). There was a slight increase in deaths between 2010 and 2011 .Boys, children of low birth order, children of youngest or oldest mothers, children of uneducated mothers and mothers who had only attended primary school and children of poor households had a statistically significant higher risk of dying compared to others. Overall, children living in the poorest quintiles of households had a risk of dying that was 1.28 (95% CI: 1.18–1.38) times greater than children living in the richest households. Children of uneducated mothers had a risk of dying that was 1.31 (95% CI: 1.12–1.54) times greater than children whose mothers had received education beyond primary school. Over the course of the study period, the risk of dying was significantly reduced by more than one-third in Ifakara and in Rufiji. Overall, in 2010–2011 the risk of dying was 0.65 (95% CI: 0.60–0.71) times lower than in 2000–2001 .Mortality disparities according to maternal educational attainment slightly decreased over time at both surveillance sites. However, reduction in the risk of dying over time for children of uneducated mothers compared to children of mothers who had received education beyond a primary school was not significant in Ifakara and Rufiji, HR: 0.97 (95% CI: 0.84–1.11) and HR: 0.93 (95% CI: 0.83–1.05), respectively .Disparities in mortality due to household wealth showed opposite patterns between the two surveillance sites. In Ifakara, mortality disparities between children living in the richest households and those living in poorer quintiles of households slightly declined over time. Only children living in households that belonged to the second quintile showed a statistically significant reduction over time . In Rufiji, wealth-based disparities in mortality widened over time. There was a significant increase between children living in the richest households and those living in households belonging to the second, third and fourth quintiles. Over time, the risk of dying for children living in the second quintile was 1.04 times (95% CI: 1.00–1.08) that of children living in the fifth quintile, for example .http://www.who.int/bulletin/volumes/94/4/15-154658). show how mortality disparities have been fluctuating over time. In 2000–2001, in Ifakara, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 0.92–2.27) higher than for children of mothers who had received education beyond a primary school. In Rufiji, this risk was 1.52 (95% CI: 1.05–2.21). In 2010–2011 this risk had decreased to 1.21 (95% CI: 0.81–1.82) in Ifakara and 1.08 (95% CI: 0.74–1.58) in Rufiji.Results for household wealth showed that over time mortality disparities between the richest and poorer quintiles worsened in Rufiji while in Ifakara, disparities narrowed slightly. In Rufiji, in 2000–2001 the mortality HR for children living in the poorest households was 1.20 (95% CI: 0.99–1.47) times higher than for those living in the richest households. In 2010–2011, the HR had increased to 1.48 (95% CI: 1.15–1.89). In Ifakara, such disparities decreased from 1.30 (95% CI: 1.09–1.55) in 2000–2001 to 1.15 (95% CI: 0.95–1.39) in 2010–2011.Many developing countries are currently undergoing rapid demographic, economic and under-five mortality transitions. In these countries, research on socioeconomic health inequalities usually focuses only on childhood mortality and its determinants.–Here we show a decline in the under-five mortality rate between 2001 and 2011 in Rufiji and Ifakara surveillance sites. However, variables such as the sex of the child, maternal age and educational attainment and the relative household wealth are still associated with an increased risk. During the under-five mortality transition, indicators of social and economic disparities have not narrowed. Thus, while our research confirms other studies in the improvement in childhood mortality, we demonstrate that equity problems remain despite this progress.–National estimates in the United Republic of Tanzania have also shown declines in under-five mortality rates during 2001 and 2011, particularly after 2005 and most prominently in rural areas.,,,,–,,Our findings on the associations between disparities in the under-five mortality rate and social and demographic characteristics of children and their mothers are consistent with previous studies in sub-Saharan Africa.,,In rural areas of the United Republic of TanzaniaIn conclusion, our findings suggest that children from all socioeconomic strata are benefitting from improved child survival. We also provide evidence that mortality disparities by maternal educational attainment and household wealth have not significantly narrowed. These results suggest that the longstanding equity problems of rural areas of the country still persist. Policies and health programmes are needed to reduce mortality, and offset social and economic disparities between population subgroups.