Introduction: Oral Verrucous Carcinoma (OVC) is described apart of the Squamous Cell Carcinoma (SCC) due to its specific properties. The objective of our study is to show our series of cases of OVC and to compare with the SCC in terms of clinical manifestations, epidemiology, histopathology, treatment and follow-up.Material and Methods: This is a retrospective study of all the OVC treated in our department between January-2007 and December-2011. The analyzed variables were sex, age, localization in the oral cavity, histopathology, number of biopsies needed to diagnose OVC, TNM classification, treatment and recurrences during follow-up. Results: Our sample was composed by n=14 patients, 57% female, with a mean age of 69.14 years. The most common localization was buccal mucosa (n=5). Seven patients were diagnosed of OVC with the first biopsy. TNM classification was: pT1: 7 patients, pT2: 3 patients, pT3: 3 patients, pT4: 1 patient. No cervical metastases were observed either in cervical neck dissection or during the follow-up of the patients. The treatment was surgery with clinical resection margins up to 1 cm in all cases, followed by radiotherapy in selected cases. Only n=1 patient (7.69%) presented a recurrence after 34 months of follow-up. The overall survival rate was 92.85%. Conclusions: In our population, OVC represents the 6.16% of all oral cavity and oropharynx cancer, and is more frequent in female patients above 70 years old. It uses to rise over a previous lesion, and usually affects the buccal mucosa. In patients with high suspicious lesions, more than one biopsy may be needed to diagnose OVC. No patient showed cervical dissemination. In our experience, treatment based on local resection, without cervical neck dissection, could be a good option for these patients. Key words:Verrucous carcinoma, squamous cell carcinoma, oral cancer, oral cavity, epidemiology, follow-up. The Verrucous Carcinoma was described by LV Ackerman in 1948 , with a Its etiology is not well known, but smoking habit, alcohol consumption and betel nut chewing are proved causes. The role of the Human Papilomavirus in OVC oncogenesis is much less important than in the SCC oncogenesis -8.Verrucous carcinoma usually debuts as an abnormal growth or as change in the consistency of a previous potentially malignant disorder of the oral cavity. All mucosal sites of the oral cavity can be affected. However, the rate of malignant transformation of a leukoplakia to an OVC is 20.81 times higher if they are located in the gingiva in comparison with the tongue .Histopathologically, it frequently shows aneuploidy , which cSurgery is the best treatment. Although an optimal disease control can be achieved by surgery only, frequent revision is mandatory due to the increased risk of second tumours .Our objective is to show our series of OVC patients, treated at our department, and to compare with the SCC in terms of clinical manifestations, epidemiology, histopathology, treatment and follow-up.We designed a descriptive and retrospective epidemiological study of patients diagnosed of OVC and treated by surgery in our institution between January/2007 and December/2011.Between those years, we collected a total of 14 OVC patients, among n=227 patients diagnosed of SCC of the oral cavity, which met the following Inclusion Criteria: pathological confirmation of OVC of the biopsied specimen of the resected tumor, surgical treatment and follow-up during more than 6 months. We excluded all patients who did not fit the inclusion criteria.The analyzed variables were: sex, age, localization in the oral cavity, histopathology, number of biopsies needed to diagnose OVC, TNM classification , treatment given and recurrences during follow-up. The statistical descriptive analysis was done using the SPSS v17.0.In our sample, 57% (n=8) were woman, and 43% (n=6) were males. The mean age was 69.14 years (range 84-46). The most frequent localization was buccal mucosa (n=5 patients), followed by lipcommissure (n=3), gingiva (n=3), tongue (n=2) and hard palate (n=1). In n=2 patients histopathological study revealed “hybrid verrucous carcinoma”. More epidemiological data are shown in et al. (The prevalence of OVC for total carcinomas affecting the oral cavity and oropharynx is low, and as revised in Rekha et al. , is betwPublished series on Asian patients, reflect its greater incidence in men with prevalence as high as 77.4%  and 94.9The involvement of buccal mucosa appears in several articles as the most common -14, as wThe need for a cervical dissection is also controversial. Case series published over the years agree that the OVC tends to grow locally but not to cause ganglionar spread ,23. HoweWe have identified an important diagnostic problem, which is the differentiation between “pure” OVC and “hybrid” OVC, which has foci of squamous cell carcinoma. The hybrid OVC can be up to 20% of diagnosed OVC, and behaves like squamous cell carcinomas regarding to their metastatic spreading tendency . In thesDuring the follow-up of our patients, only one patient had a local tumor recurrence 34 months after surgery in the buccal mucosa, biopsied as OVC again, and treated by surgery. No second tumors were found. Since the follow-up period was uneven for all patients, we can not state the recurrence rate at 5 years. Because the average follow-up was close to 2 years, we can say that the recurrence rate at 2 years of follow-up stood at 7.69%. The long-term follow-up studies of OVC patients refer highly variable recurrence rates between 0 and 66.7% at 5 years ,15,19, wThe most relevant limitation found in this article is the small size of the registered sample. Because our institution gives assistance to a population of a small city, the volume of oncological patients treated could be smaller than those that appear in other published series. Although n=14 patients represent a small sample, the prevalence of OVC among all SCC or the oral cavity in our series is similar to those published and referenced above. That is why we consider our sample as representative.Verrucous carcinoma in our series appears in patients around 70 years, usually on a previous injury, often affecting the buccal mucosa. In patients with suspicious lesions more than one biopsy to diagnose a verrucous carcinoma may be needed. No patient had cervical lymph node involvement. Local resection with at least 5 mm of histological margin, without prophylactic neck dissection allows local control of the disease with recurrence rates of 7.69% at 2 years. Overall survival rate in our series was 92.85%.


This study examines the cost effectiveness of group follow-up after participation in the Dose Adjustment for Normal Eating (DAFNE) structured education programme for type 1 diabetes.Economic evaluation conducted alongside a cluster randomised controlled trial involving 437 adults with type 1 diabetes in Ireland. Group follow-up involved two group education ‘booster’ sessions post-DAFNE. Individual follow-up involved two standard one-to-one hospital clinic visits. Incremental costs, quality-adjusted life years (QALYs) gained and cost effectiveness were estimated at 18 months. Uncertainty was explored using sensitivity analysis and by estimating cost effectiveness acceptability curves.P value, 0.052; 95% CI, −0.08 to 0.01, intra-class correlation (ICC), 0.033) and a mean reduction in total healthcare costs of €772  per patient. At alternative threshold values of €5,000, €15,000, €25,000, €35,000, and €45,000, the probability of group follow-up being cost effective was estimated to be 1.000, 0.762, 0.204, 0.078, and 0.033 respectively.Group follow-up was associated with a mean reduction in QALYs gained of 0.04 per patient .Current Controlled Trials  The Dose Adjustment for Normal Eating (DAFNE) programme, which comprises of group-based structured education sessions, has become an established strategy for enhancing self-management in individuals with type 1 diabetes,3. This Full details of the trial methods are published elsewhere. In brie1c) from baseline to follow-up. At 18 months, the trial showed no clinically or statistically significant difference in HbA1c between groups  at 2009 prices. The first related to the cost of implementing the group follow-up intervention in clinical practice. This included a range of resources such as educator and administrator time input, educational materials and consumables, post, packaging, telephone and travel expenses. This data was recorded prospectively by the study research team. The total cost of implementing the group follow-up intervention was €39,933, giving a mean cost per participant estimate of €185. This cost was allocated to all patients in the group follow-up arm.Second, costs relating to the use of primary and secondary healthcare services over the course of the trial were estimated for patients in both treatment arms. This included the costs of general practitioner, dietitian, and chiropodist consultations, diabetes day care centre, outpatient, and accident and emergency visits, hospital admissions, medications including insulin, lipid lowering, antiplatelet, and antihypertensive therapies, and blood glucose self-monitoring tests. Resource use was captured via structured questionnaires completed by patients at baseline and the three follow-up data collection points: 6, 12 and 18 months. A vector of unit costs was applied to calculate the cost associated with each resource activity at each time point. Notably, the baseline time point included the period during which the DAFNE programme was delivered. Unit cost estimates for each activity were based on national data sources and, where necessary, were transformed to Euros (€) at 2009 prices using appropriate indices see Tab. In sensMI package in Stata 13 to estimate missing values for individual resource use cost data at each time point. The imputation models for each variable included age, gender, length of illness, treatment arm, and hospital clinic, were estimated using predictive mean matching, and were based on M = 5 imputed data sets.For the purposes of the incremental analysis, a total healthcare cost at 18 months follow-up variable was constructed. The cost per individual resource activity at 18 months follow-up was calculated by aggregating individual resource costs across the three follow-up periods: 0 to 6 months, 6 to 12 months, and 12 to 18 months. The individual resource costs were then summed to compute the total healthcare cost variable. To facilitate this process, multiple imputation[1c, body mass index, heart disease status, high blood pressure status, chest or lung disease status, smoking status, medical card status, marital status, education status, employment status, and clustering. The analysis was undertaken using the MI estimate mixed and MI predict commands in Stata 13, which estimate the regression model on each of the imputed data sets and apply Rubin’s rules to generate the coefficients of interest[Estimation of incremental total healthcare cost was undertaken using a linear mixed effects regression model. The model was estimated controlling for treatment arm, baseline cost, age, gender, length of illness, HBAinterest. To accoThe adoption of two alternative model specifications for the cost analysis was examined in sensitivity analysis. First, a parsimonious model, controlling for treatment arm, baseline cost, and clustering was estimated. Second, a generalised linear model with cluster standard errors, assuming a Gamma variance function and identity link function, was estimated on the full set of covariates and factors. Notably, multilevel models based on the Gamma distribution may fit cost data better than Gaussian based approaches. We repoHealth outcomes in the analysis were expressed in terms of QALYs gained, calculated using the EuroQol EQ5D 3 L instrument,19, a stMI package in Stata 13 to estimate missing values for EQ5D scores at each time point. The imputation models for each variable included age, gender, length of illness, treatment arm, and hospital clinic, were estimated using predictive mean matching, and were based on M = 5 imputed data sets.For the purposes of the incremental analysis, a 'QALYs gained at 18 months' variable was constructed using the EQ5D scores for each participant at baseline, 6, 12, and 18 months using the area under the curve method. Once again, to facilitate this process, multiple imputation was undertaken using the 1c, body mass index, heart disease status, high blood pressure status, chest or lung disease status, smoking status, medical card status, marital status, education status, employment status, and clustering. As for the cost analysis, the analysis was undertaken using the MI estimate mixed and MI predict commands in Stata 13.Estimation of incremental QALYs gained was undertaken using a linear mixed effects model. The model was estimated controlling for treatment arm, baseline EQ5D score, age, gender, length of illness, HBAIn sensitivity analysis, a parsimonious model, controlling for treatment arm, baseline EQ5D score, and clustering, was estimated.In economic evaluation, a treatment can be defined as more cost effective than a comparator if one of the following conditions apply: (a) it is less costly and more effective; (b) it is more costly and more effective, but its additional cost per additional unit of effect, known as the incremental cost effectiveness ratio, is considered worth paying by decision makers; or (c) it is less costly and less effective, but the additional cost per additional unit of effect of its comparator is not considered worth paying by decision makers. To idenTSB command in Stata 13[To undertake cost effectiveness analysis alongside cluster RCTs, techniques which recognise the clustering and correlation in the cost and effect data must be adopted. In thisStata 13, which iStata 13.Raw data estimates for resource use and EQ5D scores at baseline and each follow-up time point are presented in Table P value, 0.020; 95% CI, −1,415 to −128; ICC, 0.016) per patient. In terms of QALYs gained at 18 months, the mean estimates were 1.35 for individual follow-up and 1.31 for group follow-up. The multilevel regression results indicate that group follow-up was associated with a reduction in mean QALYs of 0.04  per patient.The results from the incremental cost effectiveness analysis are presented in Table The expected cost effectiveness results are summarised in Table The results from a series of sensitivity analysis are presented in Additional file1c[On the basis of evidence collected alongside a cluster RCT, group follow-up care after the DAFNE programme for type 1 diabetes was, on average, less effective and less costly than standard one-to-one individual follow-up care. These results supplement those from a parallel clinical effectiveness study which reported that group follow-up had no significant effect on the primary outcome of HbA1c. Here, wIn terms of the overall cost effectiveness findings, the results for the group follow-up intervention lie in the south west quadrant of the cost effectiveness plane; that is, the intervention is less costly but less effective than the control. In this quadrant, the intervention will be considered cost effective if the amount saved is above the threshold value, λ, per QALY gained. In this1c. While a full economic evaluation was not undertaken, the authors concluded that group care was cost effective. Notably, the relatively longer follow-up period in the trial by Trento and colleagues[1c levels at 12 months for individuals with poorly controlled type 1 diabetes. However, the benefits were not observed at 4 years follow-up, thereby indicating that some form of ongoing intervention may be required[This study adds to the limited literature on the cost effectiveness of complex group-based interventions which seek to improve self-management in patients with type 1 diabetes. A study by Trento and colleagues reportedlleagues may be alleagues reportedrequired. Moreoverequired. These f1c, group-based peer support was shown to be cost saving relative to usual care. A second Irish RCT evaluating primary care clinics for the secondary prevention of coronary heart disease in Irish general practice reported significant reductions in hospital admissions and costs of care relative to usual care[From an Irish perspective, where the traditional approach to chronic disease management in the community may be described as reactive in nature, our findings highlight the potential resource implications of adopting a more proactive and systematic approach to care. This is particularly relevant given future projections of a growing number of people with chronic disease in Ireland, and conual care,32. WhilThere were a number of limitations in this study. Participants were randomised to control and intervention following the collection of baseline data, which indicate that both groups were well matched. HoweverWhile the cost analysis was conducted from the health service perspective and included a broad range of resource use activities, certain resource items were not captured; for example, the costs of diabetes eye screening were not included. Furthermore, private patient costs such as private health insurance premiums, and broader costs to society such as productivity losses were not captured in the analysis. Nonetheless, there is little to suggest that the inclusion of these resource categories would fundamentally change the results as presented. The process of conducting cost analysis in Ireland is also compromised by the lack of nationally available unit cost data. In estimating unit costs for individual resource activities, we endeavoured at all times to be conservative in any assumptions adopted. It should also be noted that we adopt 2009 prices for the analysis and medical inflation has fallen in the period since the trial was conducted. To examine the uncertainty surrounding the unit cost estimates, sensitivity analysis was conducted in which unit cost data were deflated by 10% and 50%, respectively. Neither set of results fundamentally differed from those of the base-case analysis.We employed appropriate methods for the statistical analysis of cost and effect data collected alongside cluster RCTs. Notably, clustering for the variables of interest was moderate, with ICCs of 0.016 for total healthcare cost and 0.033 for QALYs gained. Moreover, the correlation coefficient for costs and QALYs gained was −0.18. To account for potential covariate imbalances between treatment arms at baseline, we estiMI command in Stata 13. The variables included in the imputation models were pragmatically chosen by the study team and included age, gender, length of illness, treatment arm, and study centre. This approach may be criticised on the basis that values for resource use and EQ5D scores were imputed independently. Furthermore, hospital clinic was included as a fixed effect in the imputation model, reflecting recent guidance that the imputation model should be compatible with the analysis model: that is, both should reflect the multilevel nature of the data[As noted above, data were collected via structured questionnaires and, consequently, missing data was an important consideration in the analysis. Details on missing data at each data collection point are presented in Additional filethe data; howeverFinally, in the case of chronic disease, a lifetime horizon for analysis is encouraged as interventions may have long-terms implications which occur beyond the end of trial follow-up. Given tThere is little evidence to support the implementation of group care as the sole means of follow-up after structured education for individuals with type 1 diabetes. Nonetheless, given the reported cost savings, as well as the growing budget constraints facing health systems worldwide, future studies should continue to explore the clinical and cost effectiveness of alternative models of group care for diabetes.1c: glycated haemoglobin; ICC: intra-class correlation; QALY: quality-adjusted life year; RCT: randomised controlled trial.CEAC: cost effectiveness acceptability curve; DAFNE: Dose Adjustment for Normal Eating; HbAThe authors declare that they have no competing interests.SFD, MCOH and EOS conceived the study and participated in the design of the trial and intervention. PG and EOS undertook the acquisition and analysis of the health economic data. All authors participated in critical revision of the manuscript, and have seen and approved the final version.1c between Intervention and Control arms at Baseline and Follow-up. Table S2. Completeness of Data at Baseline and Follow Up Time Points. Table S3. Sensitivity Analysis 1: Parsimonious Regression Model Results: (1) Incremental Costs estimated controlling for Arm, Baseline Costs and Clustering; (2) Incremental QALYs estimated controlling for Arm, Baseline EQ5D Score and Clustering. Table S4. Sensitivity Analysis 2: Alternative Regression Model Specification for the Incremental Cost Analysis: GLM regression model, assuming a GAMMA Variance function, an identity Link Function, and clustered standard errors. Table S5. Sensitivity Analysis 3: Assuming that unit costs in Ireland are 10% less than those adopted in the Base-Case Analysis. Table S6. Sensitivity Analysis 4: Assuming that unit costs in Ireland are 50% less than those adopted in the Base-Case Analysis. Table S7. Alternative Imputation Model Specification Results: Single Level Imputation.Comparison of HbAClick here for file


Due to water shortage, municipal reclaimed water rather than surface water was replenished into recycling cooling water system in power plants in some cities in China. In order to understand the effects of the measure on carbon steel corrosion, characteristics of two kinds of foulant produced in different systems were studied in the paper. Differences between municipal reclaimed water and surface water were analyzed firstly. Then, the weight and the morphology of two kinds of foulant were compared. Moreover, other characteristics including the total number of bacteria, sulfate reducing bacteria, iron bacteria, extracellular polymeric substance (EPS), protein (PN), and polysaccharide (PS) in foulant were analyzed. Based on results, it could be concluded that microbial and corrosive risk would be increased when the system replenished by municipal reclaimed water instead of surface water. Per capita water resources of China are only a quarter of average value of the world. China was belonging to one of 13 countries with an extreme deficiency of water resources in the world . CompareIn fact, biofilm growth, pipe corrosion, and water quality deterioration have been found in the real system , 4.Using surface water to replenish recycling cooling water system has been studied systematically. Many works are concentrated in the chemical stability, corrosion, and scaling mechanism, corresponding to control technology –8. The eTwo kinds of foulants on the carbon steel coupons in the system makeup by either municipal reclaimed water or surface water were studied, respectively, by static experiment in the paper. Firstly, 23 water quality indexes of municipal reclaimed water and surface water were comprehensively analyzed by chemical methods. Then foulant characteristics of both systems, mainly including the total number of bacteria, sulfate reducing bacteria, iron bacteria, extracellular polymeric substance (EPS), protein (PN), polysaccharide (PS), and weight of foulant and its morphology, were analyzed by microbiological methods and scanning electron microscopy (SEM) technology. Based on experimental results, the effects of different makeup water resources on foulants in recycling cooling water system were discussed.# carbon steel coupons were hanged, 10 L municipal reclaimed water and 10 L surface water were added into the reactors, respectively. Then temperatures, flow velocities, and concentration ratios of the reactors were set to 35°C, 0.7 m/s, and 1.0 times. Running time was 50 days. During the experiment, national type I carbon steel coupons were adopted. Size of the coupon was 5 cm × 2.5 cm × 0.2 cm. Surface water was taken from Beijing Jingmi diversion channel (Linglong Lu sections). Municipal reclaimed water was taken from municipal reclaimed water pipeline of one thermal power plant in Beijing.Two groups of parallel artificial reactors were set, as shown in The national standard analytical methods for water quality were adopted in the experiment, as shown in Rapid microbial fluorescence detector Pi-102 produced by American Hygiene Company was employed for total number of bacteria analysis. Principle of the instrument is that ATP was released from the microbial cells through the cell lysis reagent extractant. Then luciferase reaction agent, bioluminescence reagent, was added and fluorescence was generated due to the reaction between bioluminescence reagent and ATP. At last, the total number of bacteria was determined according to testing fluorescence value.Sulfate reducing bacteria (SRB) were analyzed by MPN method according to “Examination of bacteria and algae in industrial circulating cooling water—Part 5: Examination of sulfate-reducing bacteria” (GB/T14643.5 2009).Iron bacteria were analyzed by MPN method according to “Examination of bacteria and algae in industrial circulating cooling water—Part 6: Examination of iron bacteria” (GB/T 14643.6 2009).3PO4, 4 mmol/L NaH2PO4, 9 mmol/L NaCl, and 1 mmol/L KCl, pH = 10) into the beaker. Then dip 2 to 5 cotton swabs into the buffer solution and use them to scrub coupons back and forth. Put the swabs into the beaker also. Vibrate the beaker by ultrasonic apparatus for 10 min. Add 0.3 mL formaldehyde into the beaker and stir the beaker 0.5 h at 300 r/min. After adding 50 mL 0.04 mol/L NaOH solution into the beaker, stir it for 1 h and centrifuge it for 10~20 min. Filtrate supernatant fluid by 0.45 μm microporous membrane and take clear liquid for experiment.Peel off foulant from coupons and put it into a beaker. Add 50 mL buffer solution (2 mmol/L NaProtein was tested by coomassie brilliant blue G-250 method. Standard curve of protein in the experiment was shown in Comparison of water quality of municipal reclaimed water and surface water was shown in Mn, total hardness, total phosphorus, soluble phosphorus, orthophosphate, silicon, surfactant, and total bacteria were higher. The concentrations of conductivity, TDS, chloride ion, silicon, and surfactant in municipal reclaimed water were, respectively, 1.5~2 times, 1.6~1.9 times, 1.9~4.5 times, 2.9 times, and 2.8 times higher than those in surface water. The concentrations of CODMn, total phosphorus, soluble phosphorus, orthophosphate, and total nitrogen were about 1.5~2 times higher than those in surface water. The total number of bacteria in municipal reclaimed water was one order of magnitude higher than that in surface water.According to Compared with surface water, more sulfate, calcium, phosphate, and silica in municipal reclaimed water would increase scale risks in the recycling cooling water system. However, higher anionic surfactant would play an opposite role. By comprehensive analysis according to γ-Fe2O3, which could delay the metal corrosion. Due to high chlorine ion and sulfate and low pH in municipal reclaimed water, risk of metal corrosion would increase in recycling cooling water system made up by municipal reclaimed water.Chloride ion, sulfate, orthophosphate, and pH were the key indices for corrosion. Radius of chlorine ion is small and therefore that leads to its strong penetrability or adsorption ability. Chlorine ion could destroy the structure of oxide film on the metal and result in metal into active corrosion state from passive corrosion state. Although radius of sulfate ion was of larger and lower penetrability through passivation film than chloride ion, sulfate would be reduced to hydrogen sulfide by sulfate reducing bacteria and result in low pH nearby. So the pitting corrosion of metals happened. On the contrary, phosphate was beneficial to passivation of the metal surface. Main ingredient of the passivation membrane was Mn, total phosphorus, orthophosphate total nitrogen, and the total number of bacteria in municipal reclaimed water would also increase microbial risk in recycling cooling water system.There were sunshine, high dissolved oxygen, and suitable temperature in recycling cooling water system, which were beneficial to microorganism growth. Moreover, high CODWeight of foulant in recycling cooling water system makeup by municipal reclaimed water and surface water was shown in 2, which was 0.56 times higher than that by surface water. SEM morphology in According to Foulant in recycling cooling water system in power plant mainly formed by crystallization, particle, corrosion, and microorganism. The weight of foulant is mainly composed of the first three kinds of foulant. According to results of In addition, compared with surface water, low turbidity in municipal reclaimed water would result in fewer particle foulants in recycling cooling water system.Based on the above results, when municipal reclaimed water took the place of surface water to replenish into recycling cooling water system, the amount of foulant would be lower due to reduction of crystallization, corrosion, and particle deposition, which would lead to decrease of heat transfer resistance and energy losses of the heating equipment.Comparison of EPS, PS, and PN in foulants in recycling cooling water system makeup by municipal reclaimed water and surface water was shown in According to EPS was one kind of high-molecular compound which was secreted by microorganism and surrounded outside of the cell wall under certain environmental conditions. EPS mainly came from microbial metabolism, cell autolysis, deciduous of cell material, and influent water matrix . By studMn, total phosphorus, soluble total phosphorus, orthophosphate, and total nitrogen in municipal reclaimed water were 1.5~2 times higher than those in surface water. So metabolism of microorganism was of more activity. Results of The content and composition of EPS were related to microbial species, growth status, and the types of substrate. In low organic matter and nutrient environment, available substrate by bacteria was less and its proliferation rate was low. EPS mainly came from cell autolysis and deciduous of cell material . In highComponents of EPS instead of its amount played greater role in foulant. Polyvalent metal ion, suspended organic matter, and inorganic matter in water were adsorbed by electrostatic interactions of protein in EPS. PN also could promote cell adhesion and cross linking structure formation. Higher proportion of PN in EPS would cause stronger hydrophobicity, higher cross linking degree, and more compact structure of foulant –27. PS wComparisons of the total number of bacteria, iron bacteria, and SRB in the foulant in recycling cooling water system makeup by municipal reclaimed water and surface water were shown in According to Mn, total phosphorus, soluble total phosphorus, orthophosphate, and total nitrogen in municipal reclaimed water were 1.5~2 times higher than those in surface water, which was the main reason for the higher total number of bacteria and iron bacteria in the system. Moreover, based on results in Sections In poor nutrition environment, microbial growth rate was proportional to nutrient metabolic rate. The higher the nutrient concentration, the greater the microbial growth rate. According to More microorganisms in municipal reclaimed water would increase biofilm and microbial foulant formation in the recycling cooling water system. The conclusion was in accordance with polysaccharide experimental results of 2+ to Fe3+ and produce iron oxide precipitation on the metal surface. Moreover, precipitation on the surface also led to the formation of oxygen concentration cell and thus resulted in metal corrosion accelerated. SRB was anaerobic microbe. It used lactic acid or pyruvic acid as electron donor and sulfate as electron acceptor. By redox reaction, sulfate was reduced into bivalent sulfur and corrosion products were generated. In addition, role of cathodes depolarization was also the main reason of SRB corrosion. High iron bacteria and low SRB in municipal reclaimed water meant that metal corrosion would mainly be influenced by iron bacteria when recycling cooling water system replenished by reclaimed water.Iron bacteria and SRB were typical corrosive microbes in recycling cooling water system. Iron bacteria belonged to aerobic bacteria, which could oxidize FeAbove all, in recycling cooling water system makeup by municipal reclaimed water instead of surface water, there were more numbers of microorganisms, high foulant viscosity, and more serious aerobic microbial corrosion.Mn, total phosphorus, soluble total phosphorus, orthophosphate, and total nitrogen were 1.5~2 times higher, and the total number of bacteria was one order of magnitude higher. The results showed that lower scaling, higher corrosion risk, and microbial risk would happen in the recycling cooling water system when it was replenished by municipal reclaimed water instead of surface water.According to analysis results of 23 water quality indexes, compared with that in surface water, concentrations of conductivity, TDS, chloride ion, and surfactant in municipal reclaimed water were 2~4 times higher, concentrations of CODThe weight of foulant in the recycling cooling water system makeup by municipal reclaimed water was 44% lower than that by surface water, but the total numbers of bacteria and iron bacteria in unit mass foulant were, respectively, 8.6 times and 2.7 times higher. The results indicated that heat transfer resistance and energy losses of the heating equipment would decrease but microbial corrosion would increase in the recycling cooling water system when it was replenished by municipal reclaimed water instead of surface water.EPS in foulant in the recycling cooling water system makeup by municipal reclaimed water was 74% lower than that by surface water. Proportions of PN and PS in EPS were, respectively, 27.6% and 52.4% in the system makeup by municipal reclaimed water. The proportion of PS was an absolute advantage. On the contrary, in the system makeup by surface water, PN ratio in EPS was up to 51.7%; content of PS was relatively lower. The results revealed more microbial foulant and looser foulant structure in the recycling cooling water system when it was replenished by municipal reclaimed water instead of surface water.Results of SEM showed that thicker foulant and uniform corrosion appeared in the recycling cooling water system makeup by surface water. When the system was replenished by municipal reclaimed water instead of surface water, the amount of foulant became less and metal pitting corrosion was more serious.Based on comparison of municipal reclaimed water and surface water, amount of foulant, the total number of bacteria, iron bacteria, SRB, EPS, PN, and PS in foulant on the carbon steel in recycling cooling water system makeup by municipal reclaimed water and surface water were studied, respectively, by microbiological methods and SEM technology. Main conclusions were shown as follows.


AbstractKalotermitidae), Cryptotermescolombianus, is described and new records for Cryptotermescylindroceps and Cryptotermesmangoldi are presented from the Caribbean coast of Colombia. Cryptotermescolombianus is described from two soldiers and genetic sequences. This unusual species differs noticeably from other regional Cryptotermes species for its weak and inconspicuous definition of the frontal and genal horns and its acute angle of the frons with respect to the vertex. Cryptotermescolombianus clustered with species from the Ethiopian and Oriental region and it is closely related to Cryptotermeshavilandi. Cryptotermescylindroceps is widely distributed along the Colombian Caribbean coast, commonly associated with dead wood in mangrove habitats. It also is commonly found in wooden furniture, constituting an important household pest. Cryptotermesmangoldi is reported from the Caribbean mainland for the first time.A new species of drywood termite (Cryptotermes species for Colombia, including the pest species Cryptotermesbrevis and Cryptotermesdudleyi. This new description raises the numbers of Neotropical Cryptotermes to a total of 34 species, of which 2 are fossils, 4 introduced, and 28 endemic.With these new records, there are now five  Cryptotermes is one of the best studied and economically most significant genus of drywood termites (Cryptotermesvenezolanus - nomen dubium).termites . Sixty-nCryptotermes has been poorly studied in Colombia, only three species have been recorded: Cryptotermesbrevis  proved to be an especially suitable marker , the standard ‘tree of life gene’, is less suitable as it does not amplify well in termites and have too low resolution to distinguish species.Morphological identification of termite species can be difficult as diagnostic morphological markers can be rare and are often restricted to soldiers or alates. For such taxa, sequencing of gene fragments (DNAbarcoding) is now an important molecular tool widely used to elucidate phylogenetic relationships between taxa and to identify species . Mitochoer e.g., : CytochrTermitidae from Colombia. Given that Colombia has 37 types of ecosystems , 12S rRNA (~385 bp) and 16S rRNA  were used and sequenced as described in 7 generations, 50% discarded as burn-in). The resultant tree was visualized using FigTree version 1.4.2 (http://tree.bio.ed.ac.uk/software/figtree/). Additionally, we also used MEGA 6.0. to calculate p-distance between species.Taxonomic keys from on Table . FragmenSpecimens were suspended in Sagrotan® Hand Sanitizer and images were taken with a Nikon SMZ25 stereomicroscope coupled to a Nikon Model DS-Fi2 digital camera. The software Helicon Focus® was used to stack pictures. Morphological definitions and measurements were done following Cryptotermescolombianus will be deposited in the Natural History Museum of the Alexander von Humboldt Institute of Bogotá (MIAvH) and Paratype soldier in the collection of the American Museum of Natural PageBreakHistory, New York. Specimens of Cryptotermescylindroceps will be part of the collection of the Department of Chemistry and Biology at the University del Norte, Barranquilla, Colombia. Other Colombian material is housed in the University of Florida Termite Collection in Davie, Florida.Voucher specimens are held at Freiburg University. The holotype, dealated morphotype and pseudergates from type colony of Taxon classificationAnimaliaIsopteraKalotermitidaehttp://zoobank.org/9D27B3AE-E8A0-4512-8A1E-D9E54A88A46CDealated  and the other comprising clusters of Northwest Australian-Papuan , Ethiopian-Oriental  and Neotropical species   (Table The ) Figure . CryptotCryptotermes is debated , sample COLPT1LII-56: 2 soldiers, 1 dealated, 23 pseudergates; 3 for DNA isolation. Holotype: Soldier from the previous sample (COLPT1LII-56), it will be deposited at the Arthropod Collection of the Natural History Museum of the Alexander von Humboldt Institute of Bogotá, Colombia (MIAvH). Paratypes from sample COLPT1LII-56: 1 soldier, 1 reproductive dealate. Paratypes will be deposited as follows: 1 soldier will be deposited at the American Museum of Natural History New York, United States, 1 dealated at MIAvH. Pseudergates will be part of the collection of the Department of Chemistry and Biology at the University del Norte, Barranquilla, Colombia. All measurements for dealated reproductive, holotype and paratype soldiers are reported in Tables Holotype-colony: Colombia. Magdalena Santa Marta Tayrona National Park, Gayraca Bay, 23.VI.2015  in a piece of dry wood on soil, at elevation of 12 m a.s.l  distinguish the Named for its country of origin, Colombia.PageBreakCrytotermes to Colombia and we herein report Cryptotermesmangoldi for the first time, along the Caribbean coast  . Cryptotermescylindroceps also occurred up to 100 km inland   Figure . Our datCryptotermes species recorded for Colombia: Cryptotermesbrevis, Cryptotermescolombianus, Cryptotermescylindroceps, Cryptotermesdudleyi and Cryptotermesmangoldi. Further PageBreakstudies on the diversity of termites will determine if there are more Cryptotermes in northern and western Colombia, especially at the pacific coast which has important mangroves areas.With these new records, there are now five


Introduction. The purpose of this study is to analyze the frequency of other diagnoses and findings in patients that were diagnosed with or not diagnosed with PE following the CTPA in the ED and to analyze the relationship between diagnosis and D-dimer. Instrument and Method. This study involves all patients that presented to the ED that underwent CTPA with the prediagnosis of PE. The items considered in this study were their reason for presenting to the ED and pretest clinical risks for PE, D-dimer, and CTPA results. Findings. Of the 696 cases, the most common cause was shortness of breath (59.3%). The CTPA showed that 145 (20.83%) patients were suffering from PE. Among the remaining cases, 464 (66.66%) patients had pathological findings other than PE and 87 (12.5%) patients were reported as normal. The most common pathological results other than PE found in CTPA were atelectasis in 244 (39.9%) and ground glass in 165 (23.7%), as well as nonpulmonary results in 70 (10.05%) patients. The differences in D-dimer results of patients diagnosed with PE, patients diagnosed with another pathology, and patients with normal CTPA results were statistically significant (P < 0.001). Conclusion. CTPA scanning, performed on the basis of assessment scoring, helps in discovering other fatal pathologies in addition to PE. PE is a frequently encountered disease that is difficult to diagnose, and the disease may develop a fatal course . The disThis study was conducted in the adult emergency department of a university hospital between July 1, 2010, and July 31, 2013, after the permission required was received from the local board of ethics. The study involves patients aged over 18 who underwent CTPA with the prediagnosis of PE. The relevant imaging results were reported by radiology specialists. The demographic information about patients, their reasons for presenting to the ED, clinical symptoms and findings, D-dimer results, and CTPA reports were examined retrospectively. The patients that underwent CTPA due to trauma, aortic dissection, and tumor were not included in the study. The Wells criteria  were useP < 0.05 was accepted as significance. In patients with CT findings, pathologies were tested by two-proportion Z test in PE and non-PE groups. All data were recorded and analyzed in SPSS 20.64-detector CT  was used for all patients. The records in the radiology department assured that, in the process of scanning, all patients were in supine position, the scanning covered the area from the lower part of the lung to lower cervical vertebras, image and volume scanning was 5 mm, and all cases were administered nonionic opaque agent (for patients up to 100 kg 100 mL in the form of 3 mL/s and for patients over 100 kg 100–150 mL/kg) by autoinjectors branded Missouri through the vascular access established on the antecubital vein. Furthermore, the scanning started automatically with a delay period of 12 to 20 seconds, depending on the patient, when the density of pulmonary arteries reached 120 Hounsfield units, and, in order to avoid artifact, the patients received firstly bolus serum physiologic solution, then the opaque agent, and then again bolus serum physiologic solution. The researchers firstly examined, through the reports, the filling defects in the pulmonary arterial system in mediastinal screen images. In the cases without PE, the findings of pulmonary parenchyma, mediastinum, and any pathology related to the cardiovascular system, pleural structures, and the upper abdomen were recorded. In the cases without PE, CT findings and the relationship between these findings and D-dimer results were analyzed. Furthermore, the age, gender, complaints, and rate of admission to the hospital were compared for patients diagnosed with PE, patients not diagnosed with PE, and patients that had normal CTPA results. CT findings and Wells score were analyzed by Pearson's chi-square test. Due to the abnormal distribution, Kruskal-Wallis nonparametric test was used to analyze the relation between Ct findings and D-dimer. The study comprises 696 patients, 364 (52.3%) of whom were female and 332 (47.7%) of whom were male. The CTPA results showed that 145 (20.8%) patients had symptoms compatible with PE and 464 (66.7%) patients had symptoms compatible with diseases other than PE. The imaging of 87 (12.5%) patients did not provide any pathological findings. The distribution of demographic and clinical characteristics of cases according to CTPA results is provided in The most common causes for presenting to the ED were as follows: shortness of breath in 350 (50.2%), chest pain in 93 (13.3%), back pain in 32 (4.5%), change in consciousness in 77 (11%), hemoptysis in 25 (3.5%), palpitation in 22 (3.1%), syncope in 26 (3.7%), shortness of breath and chest pain in 14 (2%), back and chest pain in 9 (1.2%), stomach ache in 13 (1.8%), and asthenia in 12 (1.7%) cases. The other causes were nausea, vomiting, vertigo, swelling in extremities, cough, and fever.P < 0.001).According to the risk scoring based on Wells criteria, 239 (34.3%) cases were in the low, 352 (50.6%) cases in the moderate, and 105 (15.1%) cases in the high risk range. The distribution of risk scoring by diagnosis is provided in Of 696 patients, 563 underwent D-dimer testing. All patients that did not have a D-dimer testing had moderate or high scores according to the Wells criteria. Wells score is compared with D-dimer results; the following results were obtained: 2971 ± 3571 ng/mL (range: 160–36000) in cases with low risk, 4362 ± 6054 ng/mL (range: 242–36000) in cases with moderate risk, and 9836 ± 10689 ng/mL (range: 805–36680) in cases with high risk.P < 0.001)  .In the cases diagnosed with PE, the emboli were massive in 22 cases, segmental in 102 cases, and subsegmental in 21 cases. The most common disorders in the cases not diagnosed with PE were atelectasis, ground glass appearance, and pleural effusion. The distribution of CT findings of cases diagnosed and not diagnosed with PE is provided in Following the first examination, tests, and treatment in the emergency department, 128 (93.1%) out of 145 patients diagnosed with PE were transferred to the department of chest diseases, and 219 (47.2%) out of 464 cases diagnosed with another disorder and 14 cases that had normal results in CT were transferred to relevant departments in consideration of the diagnosis. The rates of hospitalization according to CT findings can be seen in PE is a fatal cardiovascular disease which has been encountered frequently. Clinical evidence is important for the diagnosis of PE. 90% of the patients suffer from one or all of the following complaints: shortness of breath, chest pain, back pain, change in consciousness, and syncope . PE shouAlgorithms incorporating clinical prediction rules and/or D-dimer testing have been developed to guide the evaluation of patients presenting with suspected PE. Two such algorithms, the Wells score coupled with D-dimer testing (Wells/D-dimer), have demonstrated high negative predictive value (NPV) in large prospective emergency department (ED) studies .The risk stratification by using Wells score in non-PE and normal groups could be considered as moderate or high risk. Due to this result, further radiological assessment is essential especially in non-PE patients with similar clinical situations and risk factors.Although pulmonary angiography is acknowledged as the gold standard for the diagnosis of PE, it has not been used routinely because it is an invasive method and not available in every health center . V/P sciIn our study, the rate of PE diagnosis is comparable with the rates provided in the literature (8–39%) , 7. The In imaging, the radiological findings of patients not diagnosed with PE showed infiltrative lesions such as consolidation and ground glass appearance which may indicate pneumonia and atelectasis, bronchiectasis, and chronic lesions of obstructive pulmonary diseases that show emphysematous changes and pleural effusion.In some patients already diagnosed with malignity, new lesions were found and new mass formation was seen in the lung. In addition to pulmonary pathologies, fatal situations that change the patient management such as aortic dissection, aortic aneurism, and pericardial effusion were found.This study was done retrospectively; therefore, required information could not be found in the folder or computer record of some study patients.The study was conducted at one ED, so the results may not be generalizable to other EDs in other settings. While we examined the use of two common clinical decision rules, Wells score and PERC, there are other commonly used scores such as the Geneva score and Pisa model, which were not evaluated.Emergency medicine physicians frequently use clinical diagnosis rules to diagnose PE. They commonly perform CTPA. CTPA, a quick and accurate procedure that is accessible on a 24 h basis in most EDs, is a valuable tool for the diagnosis of PE. CTPA not only ensures that PE is noticed but also provides distinctive results for the diagnosis of other pathologies. Our study also shows that CTPA scanning, performed on the basis of assessment scoring, helps in discovering other fatal pathologies in addition to PE. That is why prediction rules such as Wells and Geneva may be revised to cover criteria for the diagnosis of PE and alternative thorax pathologies through CTA.


In multivariate analysis, age younger than 60, extracapsular LN involving the esophagus, T4 stage, and a second course of radiotherapy to the esophagus were risk factors. In conclusion, patients with T4 stage, extracapsular LN involving the esophagus, and those receiving a second course of RT should be given particular care to avoid perforation. The prognosis after perforation was poor.The aim of this study was to analyze the risk factors and prognosis for patients with esophageal perforation occurring during or after radiotherapy for esophageal carcinoma. We retrospectively analyzed 322 patients with esophageal carcinoma. These patients received radiotherapy for unresectable esophageal tumors, residual tumors after operation, or local recurrence. Of these, 12 had radiotherapy to the esophagus before being admitted, 68 patients had concurrent chemoradiotherapy (CRT), and 18 patients had esophageal perforation after RT (5.8%). Covered self-expandable metallic stents were placed in 11 patients. Two patients continued RT after stenting and control of infection; one of these suffered a new perforation, and the other had a massive hemorrhage. The median overall survival was 2 months (0–3 months) compared with 17 months in the non-perforation group. In univariate analysis, the Karnofsky performance status (KPS) being ≤70, age younger than 60, T4 stage, a second course of radiotherapy to the esophagus, extracapsular lymph nodes (LN) involving the esophagus, a total dose >100 Gy (biologically effective dose Esophageal carcinoma is a common cancer in developing countries; the overall 5-year survival has improved significantly over the past few decades but remains poor at 19% –3. PerfoBetween Jan 2007 and Aug 2011, a total of 322 patients with esophageal carcinoma received mediastinal RT in our department. These patients received RT for unresectable esophageal tumors, residual tumors after operation, or local recurrence, and at least part of the esophagus was inside the RT field. Among them, 106 received RT for local recurrence, the T distribution was T0 in 69, T2 in 10, T3 in 17, and T4 in 10; 79 of them had local lymph node metastasis. Of the 216 patients treated for the first time, the T distribution was T1 in 4, T2 in 32, T3 in 101, and T4 in 79; 124 of them had local lymph node metastasis. All the patients were informed and consented to treatment  BED−10 = nd  metastasis. These patients were not suitable for surgery because of various medical reasons. The mean total dose was 126.9 Gy (93.6–156 Gy), dose calculation based on BEDBefore RT, thoracic CT, barium meal examination and a gastroscopy was performed to exclude those with perforation and those at high risk of perforation . All but five patients had had pathologic examination, and these five patients had severe dysphasia and were diagnosed as having esophageal cancer after clinical and radiographic examination. Of the cases with pathological diagnosis, 279 had squamous carcinoma, seven had adenocarcinoma, eight had undifferentiated carcinoma, and the remaining five had other types of cancer. LNs > 10 mm in the short axis (or 5–10 mm but markedly enhanced in contrast-enhanced CT) were identified as metastatic lymph nodes.Assessment of esophageal perforation was determined by leakage on iodine examination, or if any of the following manifestations were shown on the CT scan: (i) air in the soft tissues of the mediastinum surrounding the esophagus, (ii) abscess cavities adjacent to the esophagus in either the pleural space or mediastinum, or (iii) actual communication of an air-filled esophagus with an adjacent mediastinal or paramediastinal air-fluid collection .Extracapsular LN involvement (ECLNI) was deemed positive when irregular nodal boundaries, infiltration of adjacent fat planes, thickening of adjacent fascia, and apparent invasion of adjacent structures were present . LNs infThe gross tumor volume (GTV) was defined as any disease identified in pretreatment staging procedures including CT, PET and endoscopy. The clinical target volume (CTV) was defined as the GTV plus inclusion of the regional draining lymphatics (based on the primary tumor location). The radiation field encompassed the primary lesion as well as the regional LN drainage, which included the complete extent of visible tumor with a margin of 5 cm proximally and distally along the length of the esophagus and 1.5–2.5 cm otherwise around target tissues. Regional node drainage was defined by the primary lesion location. For mid-esophageal lesions, the adjacent middle and posterior mediastinal nodes were included. For distal esophageal or GE junction lesions, the lower para-esophageal, left gastric, and lesser curvature nodes were included. However, for patients who received a second course of RT, the planning target volume (PTV) was defined as the GTV plus a 0.5-cm margin in all directions.Radiation was delivered by high-energy (6-MV) linear accelerators. All patients received 3D conformal RT, 78 of which had intensity-modulated RT (IMRT); patients receiving re-irradiation were all treated by IMRT. A total of 294 patients received 1.8–2.0 Gy per fraction per day, five days per week; 25 patients received late course accelerated RT, which was 2.0 Gy per fraction for 16 fractions, 2.2 Gy per fraction for 16 fractions, 2.3 Gy per fraction for five fractions, then 2.5 Gy per fraction for five fractions; another three patients received 1.5 Gy per fraction followed by 1.8–2.0 Gy per fraction for one day because of invasion of the tumor from the esophagus into the trachea.Concurrent chemoradiotherapy (CRT) was administered to 69 patients, and the regimens included paclitaxal and cisplatin in 54 patients, docetaxel and cisplatin in six patients, 5-fluorouracil and cisplatin in three patients, capecitabine and oxaplatin in two patients, and a single agent of cisplatin in four patients.t tests were used for univariate analysis, and logistic analysis was used for multivariate analysis.All statistical analyses were performed using the statistics program SPSS version 19.0 for Windows. Chi-square tests, Fisher exact analysis and Esophageal perforation was observed in 18 patients, i.e. an incidence rate of 5.6%. All of these patients had symptoms such as fever, cough or chest pain. After CT and iodine examination, a diagnosis of perforation was made accordingly   in the former group, and 118.2 Gy 96–132 Gy) in the latter group , and the perforation was also located at the site of the tumor, extending from the extracapsular LN. This patient died of thoracic infection eventually; the other patient, who continued RT, died one month after delivery of 65.24 Gy (BED−10) as a result of massive hemorrhage.Two patients continued RT after control of thoracic infection; one of them had a new perforation at the edge of the stent one month after delivery of 78.59 Gy  was 2 months (0–3 months) compared with 17 months in the non-perforation group, with −10. Patients with age younger than 60 years old, KPS ≤70, T4 stage, a second course of RT, extracapsular LNs involving the esophagus, CRT and a total dose >100 Gy (BED−10) were at higher risk of perforation in the univariate analysis ; nine patients had complete response or partial response, and the other three had stable disease after re-irradiation. It seemed that re-irradiation helped control the local disease in some of the patients, even achieving complete response. Previous irradiation was not an absolute contraindication, but the risk of perforation was much higher; multivariate analysis revealed that these patients had increased risk of esophageal perforation after re-irradiation. Considering re-irradiation was the only choice for some patients, and that it may have achieved local control, it appears advisable that some patients should receive a second cycle of RT. One has to weigh up the possibility of perforation; for those with T4 disease or extracapsular LNs invading the esophagus, the risk was found to be much higher. Though we cannot give the precise dose here, we suggest the total dose be as low as possible, as higher doses increase the risk of perforation.It was not known whether re-irradiation definitely increased the risk of esophageal perforation. The treatment options after local recurrence includes surgery, chemotherapy and RT –17, and The treatment after esophageal perforation is divided into treatment for perforation and related complications, and treatment for cancer. The principles of treatment for perforation are to control the infection, to prevent continuing septic contamination, to provide nutritional support, and to restore digestive tract continuity. Restoration of digestive continuity includes treatments such as esophagectomy, endoscopic clipping, placement of a self-expandable metallic stent, or T drainage . Esophaget al. . It was demonstrated that prognosis is poor once perforation has occurred, and protection of the esophagus from perforation is thus very important.This study had some limitations, being a retrospective analysis with treatment delivered differing between patients. The sample of patients with perforation in this study was small, and this may have influenced the statistical analysis. Several years may be required before sufficient cases can be gathered for further analysis, as this complication after RT is rare.In conclusion, prognosis after perforation was poor. Patients with T4 stage disease, extracapsular LNs involving the esophagus, and those receiving a second course of RT should be given particular care to avoid perforation.


Objectives. The aim of the study was to examine factors which determine stress coping styles in type 2 diabetic (T2D) patients, with regard to selected demographic variables, clinical diabetes-related variables and selected psychical variables (anxiety level and assessment of depressive disorders). Methods. 50 T2D patients, aged 59.9 ± 10.2 years were assessed by Coping Inventory for Stressful Situations (CISS), Spielberger State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI). In the statistical analysis simple and multivariable logistic regression models were used. Results. Variables significantly increasing the selection risk of stress coping style different from preferred task-oriented strategy in a simple logistic regression model are: hypoglycemia within three months prior to the research: odds ratio (OR) = 6.86  1.25–37.61), taking antidepressants or neuroleptics: OR =15.42 (95% CI 2.42–98.33), severe depression in Beck's scale: OR = 84.00 (95% CI 6.51–1083.65), high state-anxiety level: OR = 9.60 (95% CI 1.08–85.16), and high trait-anxiety level: OR = 18.40 (95%CI 2.96–114.31), but in a multivariable model, diagnosed depression is the strongest factor: OR = 32.38 (95% CI 4.94–212.13). Conclusions. In T2D patients, the strategy to cope with stress appears to be mostly influenced by psychical predisposition. Type 2 diabetes is a social disease with a high and regularly growing level of distribution worldwide, affecting more than 2.5 mln people in Poland . It is aA pathogenesis of this phenomenon is complex. Chronic stress, associated with illness and its treatment, requires appropriate preventive measures , 6. The A question arises if stress management by diabetic patients depends on selected variables of the course of diabetes, demographical variables and psychical variables. Some prospective study in type 2 diabetic patients reported the association of depression with female gender and worsening of diabetic complications but not with diabetes duration, while this association was found for anxiety .The most preferable way to manage stress, according to psychologists, is to initiate, in difficult and stressful situations, activities concentrating on task performance and problem solving. The other two possible ways to manage stress, problem avoidance and concentrating on emotions, are of a lower value when compared to the preferred, so-called task-oriented strategy (TOS), especially in the presence of chronic, incurable disease, that is, diabetes, requiring from a patient everyday self-control and self-care and acceptance of the progress of complications which deteriorate the quality of life in a noticeable way.The aim of this study was to assess the ways to manage stress in type 2 diabetic (T2D) patients, with the emphasis on the verification of factors increasing the selection risk of a style different from the preferred task-oriented strategy (TOS).Demographical variables , selected clinical diabetes-related variables, and selected psychical variables: anxiety level and depressive disorders evaluation were analyzed.2, diabetes duration 12 ± 9.6 years, and glycated hemoglobin HbAc1  9.5 ± 2.5%. In the 50 studied patients, there were 22 patients with retinopathy (including 3 with proliferative retinopathy), 7 with diabetic kidney disease, 6 with neuropathy, 6 with diagnosed diabetic foot syndrome, and 7 with at least one hypoglycemia episode within the three months prior to the research.50  patients hospitalized because of decompensated type 2 diabetes, took part in our research; aged 59.9 ± 10.2 years, body mass index (BMI) 30.8 ± 5.8 kg/mAll diabetic complications were diagnosed according to current Polish Diabetes Association recommendations  which arDiabetic neuropathy was diagnosed on the basis of clinical  examination and/or electrophysiological abnormalities in peripheral nerves. All our patients had distal polyneuropathy primarily of sensory type.Diagnostics of a diabetic foot was based on clinical  assessment of peripheral polyneuropathy presence, legs perfusion abnormalities, foot ulcers assessment, foot deformity, and other risk factors of foot trauma in accordance with the proposal of International Working Group on the Diabetic Foot  . We had 2) and 24 with obesity (BMI > 30 kg/m2). Four patients were treated with a diet, 15 with pills, 15 with insulin, and 16 with pills and insulin. In the group of 50 patients—7 patients took antidepressants or neuroleptics, in 9 patients depression was recognized beforehand, 12 smoked cigarettes, and 25 used to smoke cigarettes. Patients who were hospitalized due to acute diabetic complications  or for whom a reason for hospitalization was different than decompensated diabetes were not included in this research. All patients submitted their written informed consent to run the study, according to the Protocol of Bioethics Committee by the Medical University of Lodz, Poland (RNN/293/12/KB/27.03.2012).Ischemic heart disease occurred in 26 of the patients interviewed, myocardial infarction in 11, stroke in 5, hypertension in 41, and dyslipidemia in 37. 17 patients were diagnosed with being overweight  by Endler and Parker, in a Polish adaptation by Strelau et al. . The CISThe anxiety level assessment as a state and as a trait was made by the Spielberger State-Trait Anxiety Inventory (STAI) in the Polish adaptation of Wrześniewski et al.  STAI incA patient gives answers to 20 questions, describing how he is feeling “at this moment,” for example, “if he is calm, tense, if he feels secure” , and to 20 questions regarding how he “usually” feels, for example, “if he is pleased, sad or happy”.  . The totThe Beck Depression Inventory (BDI) in the Polish adaptation of Pużyński et al.  was usedThe two questionnaires used in our study: Coping Inventory for Stressful Situations (CISS)  and SpieThe third questionnaire, Beck Depression Inventory (BDI) in the Polish adaptation of Pużyński et al. , was notc1, and lipoprotein profile were marked.In subjects examined in the study, parameters of blood morphology, fasting glycemia, glycated hemoglobin HbAt-test for the dependent samples to compare average TOS with average EOS and AOS [Student's  and AOS ;chi-square independence test or a Fisher's exact test (depending on the expected frequencies in a contingency table) to compare frequencies or frequency distribution of chosen states of discrete variables, for example, frequency of choice of TOS to cope with stress ;simple logistic regression model in order to select so-called independent factors which increase the selection risk of nTOS to cope with stress ;multivariable regression model in order to select the “strongest” factor from independent risk factors. To “optimize” the multivariable model, a stepwise approach was used  .The following statistical methods were used in the analysis of the material compiled:α = 0.05 for all statistical tests. The calculations were made in SPSS ver. 20 program.The significance level was assumed In the assessment of coping with stress, based on CISS questionnaire, the results achieved by patients in three scales TOS, EOS, and AOS were compared.P < 0.0005) than average EOS and average AOS (P < 0.0005).The second figure shows similarly the total in CISS questionnaire in the TOS and AOS scales for each patient. For almost all patients, the values of given points for TOS are higher than the values for EOS  and highIn the next phase, all variables underwent analysis in order to check if they change the risk of choosing a non-task-oriented strategy (nTOS).c1, fasting glycaemia, diabetes duration, the presence of complications characterized as micro-  and macroangiopathy , as well as dyslipidemia, hypertension, overweight, obesity, diabetes treatment, cigarettes smoking, and the level of hemoglobin. The analysis revealed that the variables provided above, including the presence of diabetic complications, do not change the risk of choosing nTOS. However, this data is not presented in this paper. The analysis of the relationship between demographical variables, such as age, gender, and clinical diabetes-related variables with the risk of choosing nTOS, was made using a simple regression model. The group of diabetes-related variables includes glycated hemoglobin HbAOut of the parameters referring to diabetes, only hypoglycemia within 3 months prior to the research appeared as an important factor causing an almost sevenfold, statistically significant increase of the risk of choosing nTOS .P = 0.035).In the group of patients with hypoglycemia within 3 months prior to the research, only 42.9% achieved the highest score in TOS scale in the CISS questionnaire, whereas in the group without hypoglycemia, this regarded 83.7% of the patients. These frequencies differed significantly .Diagnosed depression is the only significant variable in the multivariable model. Depression recognized beforehand appeared as the strongest factor among the examined factors, increasing the likelihood of choosing nTOS in coping with stress . In the The most innovative ways to treat diabetes have only symptomatic characteristics. They can influence a delay in the development of complications and prolong and improve the quality of life. However, at this stage, it is impossible to eliminate the causes for diabetes and to cure it completely. Patients suffering from diabetes have to include the disease in their “life-span” scenario in social, family, and professional relations. Current recommendations of the American Diabetes Association and European Association for Study of Diabetes call for “patient-centered care” . As a coA psychological aspect appears to be significant as well, especially the strategy to cope with stress caused by a chronic, long-lasting disease . To shapThe results of our work revealed significantly higher average total score in CISS questionnaire in TOS in comparison to the score received in EOS and AOS scales. Bazzazian and Besharat confirmed in their explanatory model that task-oriented coping strategy may suggest better adjustment of patients to diabetes .According to our study, diagnosed depression exerts the strongest influence on the way the patients cope with stress. It is assumed that in T2D patients about 15–24% suffer from depression .In our study, diagnosed depression was recognized in 18% of patients, 14% declared taking antidepressants or neuroleptics, and 40% of the patients showed various levels of depression symptoms, assessed in the Beck's scale.From the variables analyzed, only prior diagnosis of depression is significant for the choice of TOS. In patients with recognized depression, TOS was a dominant strategy for coping with stress according to CISS questionnaire for slightly above 20% of patients and for 90% without a diagnosed depression. A phenomenon of learned helplessness, typical for depression, defined by psychologists and sociologists, involves the fact that the sick person cannot find a solution to a difficult situation, excluding orientation on the task .In the group of patients scoring more than 10 points in the Beck's scale, which indicates some level of depression, we can observe a higher risk of nTOS choice. The higher the total in the Beck's scale, the higher the risk of choosing nTOS. For mild depression, the risk is twice as high and for moderate depression more than nine times higher. Although these connections are of no statistical significance, they can indicate the patients with a higher risk of choosing nTOS in coping with stress. Severe depression causes a statistically important 84-fold increase in risk of choosing nTOS choice. Thus, although the Beck's scale measures only depressiveness as a feature known to predestine for disease development, it can be a very useful and easily accessible tool for examining T2D patients endangered with the development of depression, as well as for assessing the way of coping with stress.Depressive disorders are often accompanied by anxiety disorders (coexistence of diseases) . The patc1, fasting glycemia on the day of check-up, chronic diabetic complications, macroangiopathy, microangiopathy, and the diabetes treatment appear not to be significant. Cigarette smoking, being overweight, or obesity do not have any influence, either.Variables such as diabetes duration, glycated haemoglobin HbAThe only feature which characterizes diabetes and which is significant for coping with stress is hypoglycemia, an episode of which within the last three months prior to the check- up is connected with a nearly sevenfold increase of the risk of choosing nTOS. On the other hand, the episodes of hypoglycemia can influence the development of depression . Katon eThe limitations of our study might be twofold: a small number of patients and taking antidepressants or neuroleptics in a part of the studied group, which may affect the choice of answers to psychological questionnaires. Patients taking antidepressants or neuroleptics were not excluded from the research since we aimed at checking how this group of patients responded to the questionnaires.Coping with stress in chronic diseases such as diabetes, although very important, seems to be still a rather less studied problem compared to other discussed fields. Hence, we hope that our study may be, despite the limitations, a useful observation which confirms the role of psychological aspects of examination in the complex care of diabetic patients.As a practical implication of our results, there may be suggested screening for depressive symptoms in diabetic patients, using Beck Depression Inventory (BDI), which is an available screening tool for physicians in daily practice. As the next step, psychological examination with standardized questionnaires , available only for psychologists, might be planned in the group of patients with depressive symptoms in order to identify and help professionally patients who do not cope with stress.In conclusion, despite the above mentioned limitations, the results of this study show the need for screening in type 2 diabetic patients, including their psychological examination. A diagnosed depression turned out to be the strongest factor which determines the risk of choosing nTOS and which covers all other factors. Hence, psychical predisposition seems to exert the strongest influence on the way in which patients behave in difficult and stressful situations.The question remains how to help patients with a particular psychical predisposition to face chronic disease such as type 2 diabetes. Currently, a holistic approach research is being carried out in more than 17 countries. Its aim is to evaluate broadly defined diabetological care, including psychological and sociological aspects of high importance; coping with disease is among them .


P = 0.011) was an independent predictor for POPF. The severe complications rate was 33%. Independent predictors were BMI , ASA class III , and mean HU . In conclusion, VFA measured at the umbilicus seems to be the best predictor for POPF. BMI, ASA III, and the mean HU of the pancreatic body are independent predictors for severe complications following PD.After pancreatoduodenectomy, complication rates are up to 40%. To predict the risk of developing postoperative pancreatic fistula or severe complications, various factors were evaluated. 110 consecutive patients undergoing pancreatoduodenectomy at our institute between January 2012 and September 2014 with complete CT scan were retrospectively identified. Pre-, per-, and postoperative patients and pathological information were gathered. The CT-scans were analysed for the diameter of the pancreatic duct, attenuation of the pancreas, and the visceral fat area. All data was statistically analysed for predicting POPF and severe complications by univariate and multivariate logistic regression analyses. The POPF rate was 18%. The VFA measured at umbilicus (OR 1.01; 95% CI = 1.00–1.02;  The onlortality .Another well-known factor associated with postoperative complications is a small pancreatic duct , 7. RobeThe aim of the present study was to develop a predictive score for POPF and severe postoperative complications following PD. Therefore, the impact of different patient, tumour, and CT-derived data was analysed.n = 134). Patients from whom preoperative CT imaging was unavailable or incomplete were excluded from the study (n = 24). Preoperative data was gathered for each patient including gender, age, BMI, Charlson index, ASA score, and CT-data. Perioperative data included type of operation, duration of surgery, and perioperative blood loss. Postoperative data included localization of the tumour, histology of the tumour, radicality of resection, duration of the hospital stay, intensive care unit (ICU) admission, readmission, and complications up to 30 days after surgery. POPF was scored according to the classification system of the International Study Group of Pancreatic Fistula (ISGPF) [Patients undergoing PD or pylorus preserving PD (PPPD) at Medical Spectrum Twente between January 2012 and September 2014 were retrospectively identified from the hospital's medical database ( (ISGPF) . The sev (ISGPF) , 10. In 2, but it preferably included an area as large as possible of homogeneous pancreatic tissue. VFA measurements were performed at three different levels, at the coeliac trunk, umbilicus, and top of the iliac crest.All used CT scans were postcontrast in the portovenous phase, with slice thickness ranging from 1 to 5 mm. The diameter of the pancreatic duct, attenuation of pancreatic tissue calculated as HU of the head, body, and tail of the pancreas, and the VFA were measured with a software program for CT, TeraRecon . This software enables semiautomatic measurements of a specific region with specified HU. The diameter of the pancreatic duct was measured perpendicular to the duct in the neck of the pancreas, obtained at the level of the confluence of the superior mesenteric and portal veins. The mean HU of the pancreas head, body, and tail was measured by manually drawing a region of interest (ROI) in these regions. The ROI was in the proximity, but did not include the pancreatic duct. The minimum size of the ROI was 1 cmStatistical Analysis. Data was analysed with IBM SPSS statistics version 22. Continuous data are presented with mean and standard deviation (STD) when normally distributed or median and range (IQR) when not normally distributed. Categorical data are summarized by frequency and percentage within each cohort. The univariate associations between variables and the different groups (no POPF versus POPF and nonsevere versus severe complications) were assessed using student's t-test or Mann-Whitney U tests for continuous variables. Categorical variables were compared by Pearson chi-square and Fischer's exact test. A P < 0.05 was considered statistically significant. Variables with a P < 0.15 in univariate analysis were entered in a forward stepwise multivariate logistic regression analysis to identify independent predictors for POPF or severe complications, based on the variables that were included in the multivariate model when they increased the fit of the model (based on the −2 log likelihood).Per- and postoperative variables such as blood loss, length of stay, and readmission were not included in the multivariate logistic regression model, because these factors will not contribute to a preoperative risk prediction.2), 42% were overweight (25–30 kg/m2) and 11% were obese (>30 kg/m2). Of the patients, 36% underwent PD and 64% PPPD. The median operation time was 156 min (140–179 min) with an intraoperative blood loss of 500 mL (300–763 mL). The majority of patients had a pancreatic adenocarcinoma (47%) or periampullary carcinoma (35%). Other patients had neuroendocrine tumours (4%), or other (14%). The overall rate of POPF was 18%. Of all pancreatojejunostomy anastomotic leaks, 2 of them were graded POPF A, 9 of them POPF B, and 9 of them POPF C. By definition for POPF C reintervention was required; this group is within the severe complication group. No or nonsevere complications (Clavien-Dindo grades I-II) were seen in 67% of the patients. Severe complications, Clavien-Dindo grade ≥ IIIa, occurred in 33%. The postoperative mortality rate was 6.4%. Patient cohort characteristics are given in P < 0.15), BMI showed to be somewhat higher in patients with POPF (P = 0.13).The study cohort consists of 110 patients, 62% male, with a mean age of 66 years (±9.3). In the cohort, 47% of patients had a normal BMI (<25 kg/mP < 0.01). Patients who encountered severe complications had an increased median length of stay from 12 to 22 days (P < 0.01) and an increased risk of mortality from 0 to 19% (P < 0.01).In univariate analysis, patients who experienced severe complications were more likely to have a higher BMI . Patients who developed severe complications were more likely to have a lower mean HU of the pancreas head, body, and tail . Furthermore, patients with severe complications were more likely to have a higher VFA measured at the level of the coeliac trunk, umbilicus, and top of iliac crest . Pancreatic duct diameter was not associated with POPF or severe complications (P = 0.444 and P = 0.420).Patients who developed POPF were more likely to have a higher VFA measured at the level of the coeliac trunk, umbilicus, and top of iliac crest , ASA class III , and mean HU of the body of the pancreas  were independent predictors for postoperative severe complications after multivariate analysis. With these variables, a risk score is developed as follows: BMI . This is probably due to the different classification of complications, McAuliffe et al. studied overall complications instead of severe complications. In the study of Roberts et al. [This study showed that the mean HU of the body of the pancreas of patients who developed severe complications was significantly lower, compared to patients who did not. In a comparable study of McAuliffe et al. , nonenhas et al. , nonenhas et al. . They foNext to the differences observed in the associations between complications and HU in the studies mentioned above, also the cause of lower HU can have various reasons. It is still unclear if fatty infiltration or steatosis, measured as a lower mean HU, is the cause of this phenomenon: washin and washout of contrast agent, namely, vary depending on the pathology of tissue and according to local blood flow mechanics . Thus, tPostoperatively, 18% of the patients developed POPF. After univariate and multivariate analyses, only the VFA remained as a significant predictor. In various studies, VFA was found to be a predictor for POPF , 20, 23.Despite the interesting and useful findings of our study, the present study also has several limitations. Firstly, the study included a variation of imaging protocols since patients were admitted from other different regional hospitals. The scans were obtained with different CT-scanners and the scan protocols varied depending on the patients referring hospital. Ideally, the measurement protocol uses a fixed scan delay with a specific contrast injection rate. Secondly, the effect of small timing differences between performance of scan and arrival of contrast in the structures was not taken into account. Thirdly, the used CT-scans had slice thickness ranging from 1 to 5 mm. For fat, muscle or HU measurement 5 mm slices were detailed enough. However, exact measurement of such small structures as the pancreatic duct may be diminished due to partial volume effects. Fourthly, from some patients, CT-scans were unavailable or incomplete; these patients were excluded. This could lead to a selection bias.In conclusion, this study analysed preoperative CT images of patients who underwent PD or PPPD and investigated predictors for POPF and postoperative severe complications. VFA was found to be a significant predictor for POPF. The most significant factors to predict severe complications appear to be BMI, ASA, and the mean HU of the body of the pancreas. Based on these three variables, a risk score for postoperative severe complications after PD or PPPD was developed. To validate these results, a prospective study is required.