We assessed the risk of cancer and stunting as a result of AFM1 consumption in Nairobi, Kenya, using worst case assumptions of toxicity and data from previous studies. Almost all (99.5%) milk was contaminated with AFM1. Cancer risk caused by AFM1 was lower among consumers purchasing from formal markets  than for low-income consumers  purchasing from informal markets. Overall cancer risk  from AFM1 alone was low. Stunting is multifactorial, but assuming only AFM1 consumption was the determinant, consumption of milk contaminated with AFM1 levels found in this study could contribute to 2.1% of children below three years in middle-income families, and 2.4% in low-income families, being stunted. Overall, 2.7% of children could hypothetically be stunted due to AFM1 exposure from milk. Based on our results AFM1 levels found in milk could contribute to an average of −0.340 height for age z-score reduction in growth. The exposure to AFM1 from milk is 46 ng/day on average, but children bear higher exposure of 3.5 ng/kg bodyweight (bw)/day compared to adults, at 0.8 ng/kg bw/day. Our paper shows that concern over aflatoxins in milk in Nairobi is disproportionate if only risk of cancer is considered, but that the effect on stunting children might be much more significant from a public health perspective; however, there is still insufficient data on the health effects of AFM1.Aflatoxin M Aflatoxins are mycotoxins produced by certain fungi, ubiquitous in soils in tropical and sub-tropical areas. The maximum level for aflatoxins in foods are regulated in many countries due to their harmful effects on health, though the allowable limits vary . Aflatoxo humans .1 in raw milk at 0.05 ng/g, which is lower by one order of magnitude than the Codex Alimentarius recommendation [The European Union (EU) regulation 1881/2006  set the endation  of 0.5 n1 prevalence is variable and affected by season, weather, geographic area, and storage conditions, among other factors [1 is the 4-hydroxy derivative of AFB1, and the major toxin metabolite found in milk and urine in animals and humans exposed to dietary AFB1 [1 is considered at least 10 times less carcinogenic than AFB1, based on animal trials [In uncontrolled and unmonitored food production and distribution systems, aflatoxin levels in foods can rise to alarming levels, resulting in acute and sometimes fatal illness. Aflatoxin B factors . AFM1 isary AFB1 . AFM1 isl trials ,9.Severe aflatoxin poisoning, called acute aflatoxicosis, caused by consumption of large amounts of aflatoxins, has occurred several times in Kenya resulting in hundreds of fatalities ,10,11. T1, but all aflatoxins are believed to be carcinogenic [Carcinogenic effects have mainly been studied for AFBinogenic . Aflatoxinogenic . Similarinogenic  estimateinogenic . Risk fainogenic . Infectiinogenic . Gibb etinogenic  estimateinogenic . In the inogenic .Stunting, based on low height-for-age z-score (HAZ), is defined when height is more than two standard deviations (SD) below the standard mean . The HAZ1 exposure association with stunting is considered likely to be causal, but the mechanisms are yet to be proven and there are studies indicating a negative association between AFB1 exposure and growth impairment or stunting [1 exposure and growth rate was not observed [The AFBstunting ,23,24,25observed ,27,28. Tobserved ,25,29,301 exposure in early life and childhood was associated with reduced HAZ score in children [1, there are fewer studies on the association with growth and no proven causality or mechanism between stunting and exposure, which means that any risk assessment for stunting is purely hypothetical.In previous studies, AFMchildren , reducedchildren , reducedchildren , and stuchildren . HoweverWorld Health Organization (WHO) estimations of the global and regional disease burden of foodborne chemical toxins  consider1 exposure, stunting, and cancer risk among urban milk consumers in Nairobi, Kenya. Dietary exposure was derived from studies conducted during 2013–2016 in Nairobi, Kenya, analyzing AFM1 levels in formal and informal dairy products, milk consumption levels, and exposure of adults and children. Stunting risk was assessed based on exposure and previous stunting prevalence [1 through consumption of milk and milk products, exposure levels were calculated, and data on estimated cancer cases were used.Risk assessment of a chemical or compound through dietary exposure includes hazard identification, hazard characterization, exposure assessment, and risk characterization . In thisevalence . To asseThe analysis of milk consumption shows differences between consumer groups based on their income status varying from 148 L annually in mid-income areas up to 240 L annually in low-income areas. Milk consumption for children below 3 years in low- and mid-income areas was calculated combining several surveys using 24-h recall and self-reporting. The milk type was not specified in the studies focusing on milk consumption of children. 1 analyses (N = 619) from the studies and mean levels of AFM1 levels for different product groups collected from different income areas. Only 19 samples had levels above 0.5 ng/g of AFM1. Only three samples (3/619) were not contaminated with detectable AFM1, and 99.5% were positive for aflatoxins, with the contamination level ranging from 0 to 2.55 ng/g. The median for the AFM1 levels was lower than the mean, reflecting the large standard deviation (SD), so the few samples with very high concentration raised the mean.1 from milk consumption was assessed based on milk consumption averages in different income groups and average of AFM1 levels in milk and milk products. In Exposure to AFM1 from milk products was calculated for children below three years old .The growth reduction estimation for children below three years exposed to AFMThis risk assessment used milk consumption and milk contamination data from several studies conducted in Nairobi in order to understand the potential impact of aflatoxin contamination on the health of the urban population. While this analysis included observations from several surveys, the assessment is not as strong as it could have been if it were possible to include the same number of participants and directly measure milk consumption and test the different products consumed directly. This approach would have allowed confidence ranges using deterministic exposure assessments. Despite this, the levels used for the risk assessment reflect the distribution of samples in Nairobi, and the reported consumption is from consumers purchasing milk in the same area.Based on our results, daily average milk consumption was estimated to be approximately 440 mL in adults, with low-income milk consumers consuming more (660 mL) than mid-income consumers (400 mL). The estimate of milk consumption in low-income areas may have been biased because some of the interviewed were milk traders, who have better access to milk. However, the significant number of mid-income participants stating no milk consumption (44%) is in line with lower averages in consumption levels. The decreasing consumption of liquid milk and replacement of traditional foods with high-value (processed) products along with increasing income is a global phenomenon.Contradicting the milk consumption of adults, mid-income children below three years old consumed more milk daily (630 mL) than low-income children (400 mL). The observed variance among low-income children is higher than the average indicating wide disparity among milk intake in low-income areas. This is consistent with a common belief that milk is especially suited to children.However, this study was not concerned with the origin of the milk, but merely draws attention to the potential risk effects of aflatoxins associated with milk consumption on urban consumers. The confidence intervals of the estimates overlap, so a difference cannot be definitively claimed. The different methods used to obtain the consumption data  produced different estimates, with the studies using self-reporting estimating the consumption higher than studies using 24 h recall (complementary data). These differences were also to be expected.1 in milk and milk products in urban Nairobi are concerning. Aflatoxin levels in different product groups available in different income areas showed a trend of lower aflatoxin levels in products available in mid-income area and in all processed milk samples. The lower aflatoxin levels in processed milk samples could be the result of formal monitoring and control systems, although we do not have evidence of the extent to which these are practiced in Kenya. Clearly, the lack of any monitoring systems in informal markets enables contaminated products to be available in the markets.The prevalence and levels of AFM1 in milk, but 56% of the samples had AFM1 concentrations above 0.05 ng/g. All mean levels in all categories were above 0.05 ng/g. Although processed milk samples had with lower AFM1 levels, 49% were above 0.05 ng/g. It is not clear which level Kenya officially follows, which is creating confusion among stakeholders in the markets.Whether the lower aflatoxin levels in processed and mid-income area samples are due to stricter control or different production systems, there are still challenges. Only 3% of the samples were non-compliant with detected concentrations above the limit of 0.5 ng/g AFM1 is likely a long-standing problem, and during past 10 years, no improvement has been observed in the contamination prevalence, with almost all milk being contaminated with AFM1 [Exposure to AFMith AFM1 ,38,39,401 levels found in Kenyan milk are high. Milk in Europe is most often analyzed for AFM1, but is also the safest. The least amount of data is available from African countries, but the available data imply highest prevalence and frequent detection levels [1, in a range of 0.008 to 0.760 ng/g [In the global context, AFMn levels ,42. In B760 ng/g  and in I760 ng/g .1 exposure was 46 ng/day on average (0.8 ng/kg bw/day). Low-income consumers had higher estimated exposure levels, at 69 ng/day (1.2 ng/kg bw/day), than the mid-income consumers at 43 ng/day (0.7 ng/kg bw/day). The difference in exposure levels can be explained by lower milk intake levels among mid-income consumers, and lower levels of AFM1 analyzed in samples acquired from middle income areas. Sources of potential inaccuracy in these estimates include: milk consumption reported by respondents could be inaccurate, consumption data focused only on liquid milk, consumers of one income bracket may purchase milk in areas of another income bracket, AFM1 content most likely varies between batches, and there may be seasonal differences [1 from milk seems to be high and chronic.Total estimation of AFMferences . However1 were significantly higher than in adults, with the same total intake (46 g/day) but higher intake per bodyweight (3.5 ng/kg bw/day), due to relatively high average milk consumption and low body weight. Adults and children in low-income areas were more exposed to AFM1, especially when consuming milk sourced from low-income areas. Mid-income children were estimated to consume 41 ng/day (3.2 ng/kg bw/day) of AFM1 through milk sourced from mid-income areas compared to the exposure of 47 ng/day (3.6 ng/kg bw/day) in low-income children consuming milk sourced from low-income areas.Calculated exposure levels of children below three years to AFM1 concentration in the milk samples [1 from milk at 94 ng/per day for children and 120 ng/day for adults, which is even higher than our estimations, but the study focused on milk retailers’ households where the milk consumption was reported to be significantly higher (900 mL/day for adults and 730 mL/day for children).Another study of milk consumption and AFM samples  estimate1 in milk. The recommended standard 0.5 ng/g was based on the data available summarizing the estimated exposure levels; intakes of AFM1 from milk was estimated 0.030 ng/kg bw/day and based on milk consumption levels exposure was estimated to be 0.023 ng/kg ng/kg bw/day when a maximum level of 0.5 ng/g was used, and 0.0035 ng/kg bw/day for a maximum level of 0.05 ng/g [The Codex Alimentarius committee compared the consequences of setting the maximum allowable limit to 0.05 ng/g versus 0.5 ng/g for AFM.05 ng/g . Clearly1 exposure from milk consumption for adults. Assuming levels and consumption were similar throughout Nairobi (a reasonable assumption), there would be 0.04 cases per year for an urban population of 1,000,000 , which t trials .1 was low in this study, the effects of AFM1 on health, and especially the combined effects of mixtures of mycotoxins, aflatoxins, other dietary contaminants, alcohol consumption, and poor diet on cancer risk still remains largely unknown. The combined exposure to different aflatoxins, mycotoxins, and other contaminants in foods might cause more significant or unknown risks [Even though the cancer risk from AFMwn risks . There iwn risks  and the wn risks .1 exposure from milk could contribute to HAZ reduction of −2 or more in 2.7% of children. The mean average growth reduction in HAZ score from AFM1 exposure from milk would be −0.340. Mahdavi et al. [1 mean concentration of 9.69 pg/mL, which is in line with our findings. Aflatoxin M1 exposure was reported to be inversely related to growth in infants below six months, with a −0.013 z-score reduction in HAZ with increasing exposure [1 levels both in umbilical cord blood and maternal serum and birth weight of the infants. Again, AFM1 was detected in 98% of samples with a median concentration of 8.2 ng/kg in breastmilk (n = 160), and was associated inversely with height of infants at birth [Based on our findings, levels of AFMi et al.  reportedexposure . This stexposure  found a at birth .1, not considering that increased milk consumption by itself promotes child growth [1 and stunting association, varying results from different studies can be due to, among other reasons, the general initial health status of the studied cohort [All these studies focused on infants and breastmilk, whereas ours focused on children consuming bovine milk. Moreover, although several studies showed associations between aflatoxin and stunting, correlation does not imply causation, and it is still not definitively proven that aflatoxin contributes causally to stunting, or the magnitude, if any, on the effect on growth. In addition, estimates of contribution to stunting or based only on the effects of AFMd growth , nor anyd growth . As obsed cohort ,26.1 exposure and stunting, with variable results, but there has been less research on AFM1 exposure from milk in young children. Although some studies have analyzed the association between AFM1 in breast milk and maternal blood and stunting [Risk assessments inevitably simplify complex processes. A number of studies have examined associations between AFBstunting ,33,49,50stunting .1 may be a more serious public health consequence than liver cancer, but there is too little evidence to be certain of this. Whether the AFM1 can be linked to stunting or not, the exposure levels are evidently high among urban Nairobi children and adults consuming milk, which can be a cause of concern for consumers and policymakers, although not to an extent to deter people from consuming milk.Assuming that the estimate would be correct, and without taking the growth promotion from milk itself into account, our results indicate that aflatoxins could contribute to a non-negligible proportion of stunting cases and severity. Our study did not take any other dietary exposure or health status into consideration. Our results would imply that, when considering aflatoxins in milk, stunting and exposure to AFMIt is also important to understand the results in the context of the increasing trend in global food trade as no market remains in isolation. Food is traded more than ever  and as mHowever, food security is still an issue in Kenya, and there is a trade-off when applying strict regulatory limits . Optimal1 situation in Kenyan dairy markets since the aflatoxin problem became evident to large community in 2004, directly reflecting the dysfunctional control systems and failed interventions. To strengthen national, safe, and high-quality dairy production now and in the future, drastic changes must happen in the dairy markets.Overall, there seems to be no change in the AFM1 is scarce, and that more information should be collected in order to warrant the strict standards imposed in many parts of the world. This study also shows that consumers purchasing dairy products from informal markets are more likely to be exposed to AFM1 than middle-income consumers purchasing processed products. The focus of future studies should be on exposure from complete diets and a range of contaminants. Also, the economic costs and benefits of standards, and the feasibility of implementation, should be taken into consideration, especially for less developed countries where less strict limits might be in place. Overall, in light of the present evidence on the negative health effects of AFM1, this study indicates that milk may contribute to a non-negligible health burden, but that further research should focus on possible impacts on stunting, as this is by far the greatest potential negative health impact.We conclude that evidence of the harmful effects of AFM1 might cause stunting, either directly or indirectly. Longitudinal, cross-sectional, or ideally a clinical trial and multidisciplinary studies would be required to better understand the effects of AFM1 of milk on child development. Even more importantly, measures to generally improve food safety and mitigate food safety hazard prevalence in food and feed chains should be a high priority especially in countries where the burden of foodborne disease is very high.We acknowledge the limitations and uncertainty within this study. Most important were the limitation of available data and lack of known confounders and mechanisms of how AFM1 in milk by combining AFM1 exposure data from several studies conducted in low- and mid-income areas in Nairobi County between 2013 and 2016 [We conducted a risk assessment for AFMand 2016 ,36,45. Tand 2016  and mid-(1)1 levels in raw milk [1 and 250 traders provided data on milk consumption in their families. The milk consumption estimations were self-reported by the families. This study also concluded that most traders supplied milk directly from farms, which means that the source of the milk is close to the trading point. Daily AFM1 exposures were calculated.Data from a survey among informal milk traders in the low-income area of Dagoretti, Nairobi, which included consumption data of milk-trading families and AFMraw milk . In tota(2)1 in the milk they consumed [1 with ELISA.Data from a survey on milk consumption in children (below 3 years) from two low-income areas in Nairobi (Korogocho and Dagoretti) and the levels of AFMconsumed ,57. This(3)Data on milk consumption in adults and children (below 2 years) in the low-income area of Dagoretti and the mid-high-income area of Westlands ,58. In t(4)1 levels from milk sampled from raw and processed milk sampled in the low-income area of Dagoretti and the mid-high-income area of Westlands [1 in 291 different milk products, including both raw and processed samples.Data on AFMestlands . This stIn brief, the different data sets that were summarized included:Milk consumption estimations were conducted from a 24-h dietary recall study, portion estimations ,57, and Exposure was calculated for all the samples, product categories, both income area sources, and respective income area for the consumer group to highlight the differences in exposure. Processed products were all milk products, except raw milk samples, and were also sub-divided between the heat-treated and fermented products. Milk samples from mid-income areas were only processed milk samples, and samples collected from low-income areas included both raw and processed milk.The exposure was calculated deterministically by multiplying mean contamination level with mean consumption level and divided by body weight of estimated average 60 kg for adults based on mycotoxin safety evaluation for intake  and 13 k1 levels in milk in the above studies were all analyzed with enzyme-linked immune-sorbent assay, using a commercial competitive ELISA  [1 levels.AFMM01M-96) ,36,45. A1 levels in raw and processed milk and in total, in low-income areas, and in high-mid-income (mid-income) area; and milk consumption in total, in low-income areas, and in high-mid-income (mid-income) area, for adults and children, respectively.For the risk assessment of stunting and cancer, distributions were fitted using @Risk 7.5 Industrial  for the following categories: AFM1 levels and milk consumption best fitting to the reported consumption. When exponential distribution of milk consumption was used, the distributions were truncated to not exceed 3000 g for children and 4000 g for adults  consumed per day, among people not infected with hepatitis B virus, and 30 times higher among those infected . The pre1, AFM1 is believed to be less carcinogenic, with at least 10 times less carcinogenicity [1 data are limited, the AFB1 potency provides information estimation about the AFM1 potency. For this risk assessment, an estimate was done first using the estimate of potency suggested by the WHO, which is also an estimate 10 times lower, which then provides scenarios for cancer risks.Compared to AFBgenicity , althouggenicity . As the 1 in milk and stunting, but the estimate found by Kiarie et al. [1/kg bw/day. This estimate is higher than found in other studies [1 on HAZ score was assumed to be normally distributed but truncated at ±2 SD  in order not to have extreme values for the sake of the model. The impact on HAZ for a child was calculated by multiplying the total exposure of AFM1 with this distribution, and then calculate the percentage that had a resulting HAZ of 2 or more out of the 100,000 iterations.There are not many published associations between AFMe et al.  in Kenya studies , but was


A nationwide prevention and control campaign for leptospirosis in Thailand has led to a decreased incidence rate, but the mortality and case fatality rates have remained stable. Regarding the limited knowledge of risk factors, a case-control study of the association between environmental and behavioral exposure with severe leptospirosis was implemented to identify the risk factors among adults in Thailand. The study was conducted in 12 hospital-based sites. Hospitalized patients with suspected clinical symptoms of leptospirosis were tested for leptospirosis by culture, loop mediated isothermal amplification (LAMP), real-time PCR, and the microscopic agglutination test (MAT). All participants answered a standardized questionnaire about potential risk factors. Risk factors were identified by univariable and multivariable logistic regression. Of the 44 confirmed cases, 33 (75.0%) presented with severe illness, as determined by clinical criteria, and were categorized as severe cases. Non-severe cases were defined as patients with non-severe symptoms of leptospirosis. Living nearby a rubber tree plantation  and bathing in natural bodies of water  were both significantly associated with an increased risk of severe leptospirosis. We recommend designating rubber plantations in Thailand as high-risk zones and closely monitoring hospitalized patients in those areas.  Leptospira. Humans are rarely chronic carriers and are considered accidental hosts. Two forms of disease are found in humans: icteric and anicteric. Anicteric leptospirosis is a mild disease and typically self-limited, while the icteric form is more severe. Icteric leptospirosis, which often progresses rapidly, occurs in 5–10% of all infected patients, and is associated with severe jaundice, liver failure, renal failure, pulmonary involvement, and even death [Leptospirosis is a zoonotic disease with a worldwide distribution caused by spirochetes of the genus en death .In 2000, epidemics of leptospirosis occurred following severe flooding in the northeastern and southern regions of Thailand. There were more than 14,000 reported cases, with an incidence rate of 23.1 per 100,000 population and a case fatality rate of 2.5%  from 199Although epidemiological, serological, and molecular research have increased our understanding of leptospirosis, the association between severe leptospirosis and potential environmental and behavioral risk factors has not been adequately studied in Thailand.Leptospira spp. involved, the susceptibility of the host, the host environment, and the behavior of the host [Leptospira spp. in environmental samples and showed that severe leptospirosis in the Peruvian Amazon was associated with higher concentrations of pathogenic Leptospira spp. at the sites of exposure and transmission. Environmental factors and host behavior could therefore be significant factors in the severity of leptospirosis in Thailand. Mwachui et al. conducted a systematic review of studies on the environmental risk factors of human leptospirosis, which included 14 studies from Southeast Asia [The major factors influencing complications of leptospirosis include the serovar of the host . In addithe host . Ganoza the host  identifiast Asia . One stuast Asia .Knowledge of risk factors for severe leptospirosis can improve prevention and control measures to mitigate the incidence of severe cases. Thus, we aimed to identify the environmental and behavioral risk factors associated between severe and non-severe leptospirosis among adults in Thailand. We conducted a case-control study in 12 hospitals across Thailand. These hospitals were located in areas of high incidence of human leptospirosis cases in Thailand according to surveillance data from the national disease surveillance system .The studLeptospira species.There were seven provincial hospital sites and five district hospitals. We enrolled all patients aged 18–60 years old presenting at the hospitals between May and September 2017 with suspected leptospirosis, sepsis, acute renal failure, pneumonia, fever of an unidentified source, or suspected dengue. Patients residing in the study areas for less than two weeks were excluded from the study. All suspected patients provided informed consent to provide blood samples for leptospirosis screening by polymerasechain reaction (PCR) assay, culture, and loop-mediated isothermal amplification (LAMP) specific for the 16S ribosomal RNA gene (rrs) of pathogenic and intermediate clusters of Leptospira serogroup was determined by a microscopic agglutination test (MAT) and all confirmed Leptospira samples were defined assevere cases or non-severe cases. The severe subjects consisted of patients who were positive for Leptospira spp.inat least one test and admitted at the hospital with at least one of the following signs: conjunctival suffusion, jaundice with alanine aminotransferase (ALT) and aspartate aminotransferase (AST) three times above the normal level (>120 U/L), jaundice with serum creatinine >133 μmol/L or blood urea nitrogen >26.8 mmol/L, pulmonary hemorrhage, respiratory insufficiency with a respiratory rate >30 breaths/min, use of supplemental oxygen therapy, and/or death. The non-severe subjects consisted of patients who were admitted at the hospital without any of the aforementioned clinical signs and were positive for Leptospira spp. in at least one test. Data on demographic factors and risk factors included a history of clinical signs, dietary habits, exposure to water, work history, exposure to animals and rodents, presence of animal farms within 1 km surrounding the living areas, sharing a natural water resource with animals, personal protective equipment practices, and geographic areas such as their households and working places’ proximity to communities, rural areas, rice farms, rubber plantations and oil palm trees, and sugarcane, cassava, and fruit gardenswere recorded using a standardized questionnaire. All interviews and the collection of blood specimens were conducted in the hospitals. The Leptospira species.All participants provided a blood sample that was placed into a tube of semisolid culture medium, and immediately transported to a laboratory. Second blood samples were transferred into two tubes. One sample was treated with EDTA to extract for PCR and LAMP assays, and the other sample was placed into a tube without EDTA, in order to separate the serum for MAT. All samples were tested at the National Institute of Animal Health (NIAH) in Bangkok, Thailand. Confirmed leptospirosis was defined as a positive result in any of the following tests: polymerasechain reaction (PCR)assay, culture, or loop-mediated isothermal amplification (LAMP) specific for the 16S ribosomal RNA gene (rrs) of pathogenic and intermediate clusters of lipL32 gene, which encodes the major outer membrane of pathogenic Leptospira spp. [® nano instrument  at 45 cycles. Positive samples of the lipL32 gene were molecularly and genetically identified.Real-time PCR was carried out by targeting the 241 bp region of the ira spp. ,13,14. T® reaction buffer , 4 mM MgSo4 , 1 M Betaine , 0.4mMdNTPs , 0.5 mM MnCl, 25 µM Calcein, and 8 units Bst DNA polymerase . The reaction mixture was incubated at 61 °C for 90–120 min in a heating block and then heated at 80 °C for 2 min to terminate the reaction. The presence of Leptospira DNA was defined on the basis of detecting a green color with the naked eye. DNA in all blood samples was extracted using the QIAamp DNA Mini Kit . DNA samples were kept at −20 °C until use. The LAMP assay was carried out using primers and conditions previously described by Suwancharoen et al. . This meThe blood samples were cultured in EMJH semi–solid media  at 30 °C for 12–16 weeks. The presence of leptospires was examined by dark field microscopy to observe the motility and the characteristic thin helical structures with prominent hooked ends [L. interrogans serogroups Australisserovar Bratislava, Autumnalis, Ballum, Bataviae, Canicola, Celledoni, Cynopteri, Djasiman, Grippotyphosa, Hebdomadis, Icterohaemorrhagiae, Javanica, Louisiana, Manhao, Mini, Panama, Pomona, Pyrogenes, Ranarum, Sarmin, Sejroe, Shermani, Tarassovi, and L. biflexa serovar Patoc. The panel of antigens was obtained from the WHO/FAO/OIE Collaborating Centre for Reference and Research on Leptospirosis, Western Pacific Region, Brisbane, Queensland, Australia. A MAT-positive result was set at a titer of ≥1:400.The MAT was performed with a panel of 24 reference serovars based on the standard method described by the WHO/FAO/OIE Collaborating Centre for Reference and Research on Leptospirosis ,18. The All data were entered into Microsoft Access version 2007. Data management and all analyses were performed using Epi-Info, version 7. Differences in demographic and clinical variables between the severe cases and non-severe cases were described using a chi-squared test and by Fisher’s Exact test. Univariable and multivariable logistic regressions were performed to estimate the odds ratios (OR) and 95% confidence intervals (CI) of various potential risk factors for severe leptospirosis. In order to investigate whether any association was caused by confounding factors, multiple logistic regression analysis was performed. The model was reduced in a backward elimination procedure. A 10% change in the coefficient was considered evidence of possible confounding. The sex of the patient and the presence of underlying disease(s) were considered the most important potential confounders, and were forced into the final model, regardless of their univariable significance. Adjusted OR’s and 95% CI’s were also calculated. A 2-sided p-value of less than 0.05 was considered statistically significant in all analyses.All eligible participants were invited to participate in the study through a letter informing them of the requirements and each participant signed a written informed consent document before enrolment. All study procedures were reviewed and approved by the Ethics Committee for Research in Human Subjects, Department of Disease Control, Ministry of Public Health, Thailand (FWA 00013622) on 26 December 2016. Leptospira infection. There were no signs of growth by culture. Of the 44 patients with a confirmed Leptospira infection, 28(63.6%) were cases with typical clinical leptospirosis, 10 (22.8%) were cases with fever of an unidentified source, 2 (4.5%) were cases with acute renal failure, 2 (4.5%) were cases with pneumonia, 1 (2.3%) was a case with sepsis, and 1 (2.3%) was a case of suspected dengue. The case fatality rate was 2.3% (one death of 44 confirmed patients). Of the 44 laboratory-confirmed cases, 33 (75.0%) presented with severe illness and were categorized as the case group while 11 (25.0%) presented with non-severe symptoms and were categorized as the control group. There were significant differences in terms of clinical factors includingchill, conjunctival suffusion, jaundice, breathlessness, and oliguria between the two groups as shown in Of the 173 suspected patients, 44 (25.4%) had a laboratory-confirmed The three most common serogroups identified in infected subjects were Australis (22/38–57.8%), Icterohaemorrhagiae (3/38–7.9%), and Pyrogenes (3/38–7.9%) as shown in When exploring the behavioral and environmental risk factors for leptospirosis , living After the multivariable analyses  and adjuLiving near a rubber plantation and bathing in natural bodies of water were the main risk factors for developing severe leptospirosis in our study population. This study is the first, to our knowledge, to investigate environmental and behavioral risk factors associated with severe leptospirosis in Thailand. Leptospira serovars found in rubber tree plantations and natural bodies of water.Living nearby rubber tree plantations and bathing in natural bodies of water two weeks before the onset of illness are activities associated with agricultural and outdoor occupations, which are typically associated with the transmission and infection of leptospirosis . These tLeptospira serogroups have been shown to be associated with the severity of disease in humans [Leptospira interrogans serogroup Icterohemorrhagiae was linked to severe outcomes [In our study, severe cases were more likely than non-severe cases to be infected with Icterohaemorrhagiae serogroups. Infectious n humans ,23. In boutcomes . From a outcomes , the mos−1 (mean of 298 rats ha−1) [Leptospira pathogens from the urine of infected rats may contaminate soil and water in rubber plantations, and may also spread to nearby areas. In addition, rodents are natural carriers of both serogroups Sejroe and Icterohaemorrhagiae in Thailand ,28,29,30ts ha−1) . In addits ha−1) ,37. ThesLeptospira ishigh, thus the inoculation dose for patients was high, leading to severe leptospirosis. Rodents are likely to contaminate ponds or stream water [Leptospira organisms. Leptospira survives better in stagnant river water than in rainwater or underground water [Leptospira organisms through contact with stagnant water.In natural bodies of water, it is likely that the concentration of highly pathogenic am water ,39 wherend water  due to ind water . Among oLeptospira infections was relatively small (n = 44 cases). In addition, our study is likely to be affected by selection bias. The probability of hospitalization of severe cases and non-severe cases might differ and could be influenced by the exposure. Non-severe cases of leptospirosis were the most common form of the disease, accounting for approximately 90% of the cases. Only 10% of non-severe cases were admitted to the hospital [Our results are to be interpreted in light of some limitations. The number of confirmed hospital ; therefohospital ,42. Anot


Vascular dementia (VD) is a commonly-seen disease in the elderly. What is more, “Acupuncture at 3-points for intelligence” is one of the most important components of “Jin's three-needle therapy” created by Rui Jin, a professor of Guangzhou University of Chinese Medicine, which can be used in the VD patients. In this article, researchers will assess the clinical efficacy and safety of acupuncture at 3-points for intelligence in the treatment of VD.A systematic literature search for articles up to September 2018 will be conducted using 9 databases: PubMed, Cochrane Library, Embase, CNKI, CBM, VIP, Wanfang database, OASIS, and CiNii. Inclusion criteria are randomized controlled trials (RCTs) of acupuncture at 3-points for intelligence on treating VD. The primary outcome measures will be scores reflecting the neurological function of participants based on common medical scales. Hemorheology indexes, homocysteine (Hcy), acetylcholine (Ach), nitric oxide (NO), and adverse events will also be assessed. Stata V.13.0 software will be used for data synthesis, sensitivity analysis, meta-regression, subgroup analysis, and risk of bias assessment. A funnel plot will be developed to evaluate reporting bias. Egger and Begg tests will be further performed to conduct quantitative evaluation of publication bias and to evaluate the symmetry of funnel plot. We will use the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence.The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.Our study will provide the evidence for the clinical efficacy and safety of acupuncture at 3-points for intelligence in the treatment of VD. This study will assess the clinical efficacy and safety of acupuncture at 3-points for intelligence in the treatment of Vascular Dementia.Two reviewers will independently conduct the data extraction and risk of bias assessment.The Grading of Recommendations Assessment, Development, and Evaluation system will be applied to further evaluate study findings.There may be a language bias, as both English and Chinese studies will be included.There may be clinical heterogeneity due to variations in treatment frequency and duration and the use of additional therapies.11.1 Some findings have shown that obesity, underweight, diabetes, hyperlipidemia, smoking, atrial fibrillation, hyperhomocystinemia as well as hypertension are possible vascular risks for VD.,3 Besides, the metabolic syndromes, including insulin resistance, hypertension, and dyslipidemia, are connected to lower cognitive performance which increases the odds of dementia onset. And one of the most important pathological factors of VD is poststroke, for the reason that transient ischemic attack does huge harm to cerebral vessels. VD not only shorten human life, but also lower patients and their family's quality of life, even impose economic burden.,6 Current evidence represented that antihypertensives and statins might cut down the incidence of dementia. However, there are only few effective therapies for VD which the underlying mechanism of its pathology remains unclear. Fortunately, the ancient Chinese healing technique, acupuncture therapy—acupuncture at 3-points for intelligence, which is a kind of JIN's 3-needle therapy, are widely used in treating VD patients in China. What's more, acupuncture is generally considered safe when performed correctly.With a high incidence in the elderly, vascular dementia (VD) is characterized by chronic brain ischemia and progressive memory decline.1.2 GV24 is located on the head, 0.5 cun directly above the midpoint of the anterior hairline. GB13 is located on the head, 0.5 cun above the anterior or hairline, 3 cun lateral to GV24, at the junction of medial two-thirds and lateral third of the line connecting GV24 and ST8, which is shown in Figs.  As it is shown in Fig.  Furthermore, acupuncture at 3-points for intelligence has been proven to have a definite clinical effect on the treatment of primary insomnia and poststroke depression. Many clinical trials have shown that acupuncture treatment can improve the cognition by removing oxidized biochemical substances and promoting the release of neurotransmitters, which revealed that the mechanism of promoting angiogenesis in acupuncture and moxibustion is the core of VD treatment.,16 There have been no relevant systematic reviews and meta-analyses on the effects of acupuncture at 3-points for intelligence on the treatment of VD. In addition, there is insufficient evidence to support the widespread application of acupuncture at 3-points for intelligence on the treatment of VD. Consequently, an exploration of this therapy's effect on VD is needed. In this study, researchers plan to conduct a systematic review and meta-analysis to evaluate current evidence on the effects of acupuncture at 3-points for intelligence on VD.“Acupuncture at 3-points for intelligence” is one of the most important components of “Jin's 3-needle therapy” created by Rui Jin, a professor of Guangzhou University of Chinese Medicine. Acupuncture at 3-points for intelligence is composed of 3 acupoints: Shenting GV24) and Benshen .4 and BenResearchers will include randomized controlled trials (RCTs) with no language restrictions that compare the effects of acupuncture or electroacupuncture with usual care or placebo acupuncture.22.12.1.1We will include all RCTs to assess the safety and efficacy of acupuncture at 3-points for intelligence therapy in the treatment of vascular dementia, regardless of the course of treatment, the age, course of disease, gender, and ethnicity of the patients. There is no restriction on language or publication status.2.1.21.Diagnostic and Statistical Manual of Mental Disorder 4th, DSM-IV.2.National Institute of Neurological Disease and Stroke—Association Internationale pour la Rechercheer l’Enseignement et Neurosciences, NINDS-AIREN.3.International Classification of Disease, ICD-10-R.4.Alzheimer disease diagnosis and treatment center, ADDTC.We will select patients with both cerebrovascular disease and dementia, in which cerebrovascular disease is the prominent but not the only absolute cause of dementia. All patients should be diagnosed as VD according to at least one of the current or past definitions or guidelines of VD, such as:There will be no limitation on age, sex, and ethnicity of participants.2.1.32.1.3.1We will include RCTs using only acupuncture at 3-points for intelligence (including ordinary acupuncture and electroacupuncture) or acupuncture at 3-points for intelligence with routine treatment of the control group. The difference between acupuncture at 3-points for intelligence and traditional acupuncture is that the traditional acupuncture involves inserting needles into classic acupoints of traditional meridian, while acupuncture at 3-points for intelligence only select 3 acupoints at a time, Shenting (GV24) and Benshen . Some RCTs will be excluded . There is no restriction on the length and frequency of treatment.2.1.3.2The control intervention will include sham acupuncture, placebo acupuncture, no treatment, medication , or other active treatments .1.Acupuncture at 3-points for intelligence monotherapy compared with sham or placebo treatment.2.Acupuncture at 3-points for intelligence monotherapy compared with black control group.3.Acupuncture at 3-points for intelligence plus another medication or active treatment compared with another medication or active treatment.4.Acupuncture at 3-points for intelligence plus another medication or active treatment compared with sham or placebo treatment plus another medication or active treatment.We will analyze the following comparisons:2.1.4The primary outcome measurement will be scores reflecting the neurological function of participants based on certain common scales: minimental state examination (MMSE), Activity of Daily Living Scale (ADL), Montreal Cognitive Assessment (MoCA), Hachinski Ischemic Scale (HIS), Hastgawa Dementia Scale (HDS), Blessed dementia scale (BDS), National Institutes of Health Stroke Scale (NIHSS), Hamilton depression scale (HAMD) and so on.The secondary outcome measurement will be hemorheology indexes, Hcy, Ach, NO, and adverse events.2.22.2.1We will retrieve literature in the following databases from their respective inception to September 2018: PubMed, Cochrane Library, Embase, 4 Chinese databases , 1 Korean medical database (OASIS), and 1 Japanese medical database (CiNii). The search terms will be “vascular dementia” OR “vascular cognitive impairment” OR “VD” AND “Zhi 3-needle” OR “Zhisan Needle” OR “Zhisanzhen” OR “Jin's 3-needle” OR “Jin's 3-needle” OR “3-points for intelligence” OR “acupuncture” OR “moxibustion” OR “needle” OR “electroacupuncture.” The Chinese, Japanese and Korean translations of these terms will be used for databases search of corresponding countries. The search strategy for PubMed is given in Table http://www.prisma-statement.org)  will independently scan the full texts of potential eligible studies. A third reviewer will discuss and settle the discrepancies about inclusion in the meta-analysis. And we will produce Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart to set out the number of articles identified, screened, included, and excluded. Reasons for exclusion and ascertaining eligible studies will also be shown. The study selection process will completely be stated in a PRISMA flow chart (rg) Fig. .2.2.2We will exclude articles of which no data on scales outcomes are presented, results are reused, or related information are not available. Two reviewers (TL and ZS) will independently screen titles and abstracts to select potential references according to the criteria mentioned above. If necessary, reviewers will examine full texts to identify eligible studies. Endnote V.X7 software will be utilized to manage literature and remove duplicate literature.2.3The reviewers will extract the characteristics of the included studies  by using a self-developed data extraction table. The following items will be included in the data extraction form: title, first author, funding year of publication, country of study, design, inclusion and exclusion criteria, methods of randomization, allocation concealment, age, sex, sample size, dose, follow-up time points, compliance, primary and secondary outcomes, method of outcome assessments, blinding of outcome assessment, adverse events. Any disagreement will be resolved by consensus or consultation with the third reviewer.2.3.1If necessary, we will attempt to contact authors of studies by email or telephone for missing data or clarification about evaluation scales. If we could not obtain sufficient information in this way, we will analyze the available data. We will try to evaluate the potential influence of missing data on the review results (in the Discussion section).2.4Risk of bias for each included RCTs will be assessed by 2 authors (ML and SJ) according to the Cochrane Handbook for Systematic Reviews of Interventions. This recommends the assessment of several sources of bias, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias. We will try to describe the risk of bias reported in each study. Thus, we will be able to judge the risks as low, high, or unclear (unclear or unknown risk of bias). If necessary, we will contact authors of included articles for further information.2.52.5.12 test statistics will be performed to evaluate the heterogeneity of the included studies. For the Q statistic, P < .05 will be considered as indicating significant differences. For the I2 statistic, I2 < 25% indicates no significant heterogeneity, I2 = 25% to 50% is considered moderate heterogeneity and I2 > 50% indicates strong heterogeneity. If there is heterogeneity, data will be analyzed with the random effects models, otherwise, the fixed effects models will be adopted.Stata V.13.0 software will be applied for data analysis. 95% CIs and weighted mean differences will be calculated. Risk ratio with 95% CIs will be used to express the estimate of the effect for dichotomous outcomes. For continuous outcomes, we will express the estimate of the effect as mean difference with 95% CIs. The Q and I2.5.2We will explore the possible sources of heterogeneity by conducting sensitivity analysis, partial sequence analysis, and subgroup stratification analysis. The process needs to be implemented according to the different research features, such as research types, locations, racial difference, sample size, gender differences, quality of research, adjustable or unadjustable confounding factors, treatment, and other related parameters. If the extracted data is insufficient for quantitative analysis, qualitative analysis will be carried out.2.5.3P < .1 as having statistical significance .A funnel plot will be developed using software to qualitatively assess the reporting bias of the included studies. We will further use Egger and Begg tests to conduct quantitative evaluation of publication bias and to evaluate the symmetry of funnel plot. We interpret the value of 2.6The quality of the evidence of the included studies will be evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Due to the possible limitations of the study, inconsistencies, inaccuracies, indirect evidence and reporting bias, the quality of evidence for each study will be graded as 4 levels: high, moderate, low, or very low.3Our expected goal is to publish this systematic review and meta-analysis in a peer-reviewed journal. Our article will provide information on the safety and efficacy of acupuncture at 3-points for intelligence in treating VD patients compared with other conventional treatments. This study will not involve participants’ privacy, therefore ethical approval is not required.4 Acupuncture at 3-points for intelligence is effective and safe which is suitable for patients with VD.,19 In particular, the effect of electroacupuncture at 3-points for intelligence on VD is extremely significant. Previous studies have indicated that acupuncture at 3-points for intelligence can obviously improve the intelligence level and cognitive function of patients with VD. The incubation stage of cognitive evoked potential P300 and the amplitude of N2 and –P8b are significantly improved, indicating that the cognitive functions of patients are significantly ameliorated. One study has reported that acupuncture is considered a preferable alternative pharmacotherapy for treating relevant outcomes in dementia such as behavioral disturbances. Research has also reflected a beneficial effect of additional acupuncture on cognitive status and activities of daily living for VD patients.Acupuncture at 3-points for intelligence is a form of acupuncture that has been used in clinical practice for more than 30 years in China.Acupuncture at 3-points for intelligence has been developed to treat VD, but the efficacy of the therapy compared with medications for VD is unknown. From a medical perspective, treatments, and/or management of dementia and its prevention require a long-term care rather than short-term intensive treatment. Therefore, compliance, economic costs, safety, and efficacy of the interventions are quite important. The purpose of this review is to systematically assess the effect of acupuncture at 3-points for intelligence on treating VD. We aim to collect enough studies to ensure the meta-analysis more convincing. We expect to find that acupuncture at 3-points for intelligence therapy has a positive effect on the treatment of VD. In summary, this review will be the first to evaluate the impact of acupuncture at 3-points for intelligence on the treatment of VD. The results of this review may help to establish a better approach to treat VD and provide reliable evidence for its extensive application.WS, ML, and DX conceived the study and drafted the protocol. JL, CJ, LZ, and WW revised it. TL, ZS, YX, SJ, and LW developed the search strategies, conducted data collection, and analyzed independently. All authors have approved the final manuscript.Conceptualization: Tong Lin, Danghan Xu.Formal analysis: Zhizhong Sun, Liang Zheng.Investigation: Shuliang Ji.Methodology: Yizi Xie, Lin Wang.Resources: Tong Lin.Software: Jietao Lin.Writing – original draft: Weipeng Sun, Minying Li.Writing – review & editing: Chao Jia, Wei Wu.


Cutaneus squamous cell carcinoma (SCC) is the second most common type of nonmelanoma skin cancer. SCC is a malignant neoplasm of the skin characterized by aberrant proliferation of keratinocytes.We report multidisciplinary surgical management of a 36-year-old male who presented with a huge cutaneous protruding tumor of the cervicothoracic wall. Clinically, he presented with a growing mass on the anterior cervicothoracic wall 3 years ago. Microscopic examination revealed SCC. He underwent complete excision of the lesion. The patient neglected attending our oncological department for receiving chemotherapy. Today, one year after surgery, he is alive without evidence of disease recurrence.SCC treatment depends on location of the lesion, involvement of neighboring structures, functional level of the patient, and the patient’s acceptance of the proposed management strategy.We conclude that SCC can grow to a huge size if left untreated. Surgery by a multidisciplinary surgical team is the primary mode of treatment, followed by chemotherapy if necessary. It is t2A 36-year-old male presented with a 3-year history of a growing mass on the anterior cervicothoracic wall. Biopsy of the lesion revealed moderately differentiated epithelial proliferation with focal keratinization consistent with cutaneous SCC. The mass was a protruding, ulcerated, multilobular, mostly necrotic, foul-smelling, cauliflower-like, firm tumor with hyperkeratotic zones, measuring 11 × 9.5 cm in size that had developed over a large region of erythematous skin , Fig. 2.His medical history included a personality disorder for which he took medication intermittently because of poor compliance and social support. No lymph node or distant metastases were noted. He consented to surgical reconstruction, and the tumor was excised completely with a 2–3 cm clear margin around it. The tumor appeared to have infiltrated the subcutaneous tissue, and thus, a 4-cm margin of subcutaneous tissue was excised with the tumor. Following this, wide tumor excision of the surrounding skin could not be approximated, and the surrounding skin was left to heal slowly with re-epithelialization.Neck CT showed a lesion infiltrating the inferior margin of the sternocleidomastoid muscle and prethyroid muscles in the deep plane. The tumor was connected to the anterior margin of the isthmus and the upper margin of the left thyroid lobe, extending to the level of the thyroid cartilage. At its anterior margin, the tumor showed signs of ulceration and had a diameter of approximately 135 × 43 × 65 mm. Thoracic CT showed an irregular-appearing, ulcerated mass in the anterior margin of the base of the neck, without any apparent signs indicating compromise of the visceral space. The mass was in contact with the anterior margin of the sternal handle . Needle Multidisciplinary management was performed by surgery of the breast and soft tissues, head and neck, thorax, plastic and reconstructive microsurgery deparments; intraoperative findings showed an ulcerated, necrotic, and stinking tumor lesion measuring 15 × 12 cm in the cervical region with compromise of subcutaneous cellular tissues, prethyroid muscles, inner third of the left clavicle and anterior wall of sternal notch. Then, we decided to perform wide local resection of the neck tumor before margins marking  neck plus bilateral cervical lymphatic drainage plus resection of the inner third of the left clavicle plus disinsertion of the sternal hairpin and resection of the anterior wall of the sternal notch . FinallySkin and soft tissue pathology, report a squamous cell infiltration of severe to moderately differentiated keratinizing cell carcinoma with invasion level hypodermis compromise.No malignancy were report from soft tissues and the bones. No lymphovascular and neural invasion was not evident. Bilateral lymph node ganglionic groups III, IV, V were negative.3Squamous cell carcinoma (SCC) is defined as the malignant proliferation of keratinizing cells of the epidermis. It is associated with chronic inflammation caused by radiation exposure (phototype I-II), chronic wounds , chemical carcinogens, immunosuppression, several genetic diseases, (that involve Bax immunoreactivity [psoriasis vulgaris]) and chronic infection, such as human papillomavirus infection ,8. SCC aIn the present case, although the affected area was not one of the most frequent sites for this cancer, cervicothoracic region receives considerable solar exposure. Worldwide, head and neck cancers have the seventh highest mortality, of which 5.8% cases occur in Latin America . In receDifferent histopathological types are observed in SCC. One is the verrucosa type, which is characterized by a well differentiated lesion showing locally invasive growth, with low metastatic potential and exophytic growth, as seen in our patient. Other variants include fusiform (which occurs more frequently in elderly patients), desmoplastic (highly infiltrative growth), acantholytic, and adenosquamous . Its diaGenerally, early stage cancers show favorable clinical response and prognosis; however, a small proportion of SCCs present with rapid and aggressive growth with significant infiltration of perilesional tissues, eventually growing into a giant SCC (size > 5 cm). This is common in patients with particular sociodemographic characteristics, such as low educational level, poor personal hygiene, difficulty in accessing health services, and fear of possible cancer management , as obseAdditionally, it is not uncommon for patients to choose home treatments for extended periods of time, as reported by a descriptive study in which 84.3% of the sample population used alternative therapies for an average of 11 months . Our patSCC treatment depends on location of the lesion, involvement of neighboring structures, functional level of the patient, and the patient’s acceptance of the proposed management strategy. Surgical removal with intraoperative margins > 2 cm still remains the fundamental strategy, with a cure rate of 95% with negative margins .For tumors smaller than 2 cm, a margin greater than 5 mm is maintained, and for tumors greater than 2 cm in size and 6 mm in depth, a margin greater than 1 cm must be maintained.The indications of sentinel lymph node biopsy, are high risk patients, stage III (TNM) classification for cutaneous carcinoma of the head and neck, perineural invasion, and Breslow 4 (between 2–4 mm) . Our patIn a meta-analysis of 19 reports, 130 non-anogenital SCC patients were found to have positive sentinel lymph nodes in 12.3% of patients had tumors > 2 cm in diameter, 11% had T2 tumors, and 60% had T4 tumors.If the initial resection is incomplete, the recurrence rate increases to 75% and 95% 2 and 5 years after initial diagnosis, respectively. Metastasis occurs mainly to the regional lymph nodes, followed by the lung, and liver; it rarely occurs in the brain, skin, and bones .Radiotherapy is used as neoadjuvant treatment in cases of involving large tumors, special localization as face or hands, and as adjuvant management is useful in cases of R0 patients, perineural compromise, positive margins, impossibility of total surgical resection, tumors in head and neck, trunk, and limbs undergoing lymph node dissection.Radiotherapy is also used as a palliative treatment depending on comorbidities and inoperable critireas, such as contraindicated multiple tumors, warty type, genodermatosis , scleroderma, tumors due to irradiation, poorly vascularized tumors, advanced injuries, joints and tendons.Other alternative therapies, such as cryosurgery and electrochemotherapy, are also available . The benAccording to the European consensus of 2016, carried out by the European Dermatology Forum (EDF), the European Association of Dermato-oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC), clinical examinations must be performed annually for 5 years for patients with low risk; in patients with high risk, clinical examinations should be performed every 4 months during the first two years, every 6 months from the third to the fifth year, and then annually.Ultrasound control should be performed in the clinical follow-up of patients for two years, and in cases of advanced or regional disease every 3 months for 5 years, and CT and/or MRI should be performed every 6 months for 5 years as there is a high risk of regional relapse and distant metastasis, with a high probability of occurrence of new skin tumors .4SCC of the skin is an aggressive and rapidly growing malignant tumor that can reach an enormous size if neglected. Early detection can confer good patient prognosis, reducing the risk of morbidity and mortality. The invasiveness of the tumor depends on its size, anatomical location, and histological subtype. Multidisciplinary management, such as the type used in this case, allows for a better prognosis. Surgery is the mainstay of treatment even for giant tumors, followed by oncological monitoring for reducing the risk of metastatic spread.Nothing to declare.The study is exempt from ethnical approval in our institution.Written informed consent was obtained from the patient for publication of this case report.Dr. Lopez, Dr Fory and Dr Conrado: Evaluation and post-operative managementof the case along with surgical assistance.Dr. K. Moreno, Dr Garcia, Dr Buitrago and Dr Mogollon: Performed the surgical technique.Dr. Pedraza, Dr Lopez: Assisted the surgical procedure.N/A.Mauricio Pedraza CiroNot commissioned, externally peer-reviewed.Nothing to declare.


Supplemental Digital Content is available in the text Lumbar fusion is considered to the gold standard for treatment of spinal degenerative diseases but results in adjacent segment degeneration and acquired spinal instability. Total disc replacement is a relatively new alternative avoiding the occurrence of the above complications. The systematic review and meta-analysis was designed to evaluate whether total disc replacement exhibited better outcomes and safety.PubMed, Web of Science, Embase, the Cochrane Library, Chinese National Knowledge Infrastructure Database(CNKI), Wangfang database, and VIP database were searched for RCTs comparing total disc replacement with lumbar fusion. All statistical analyses were carried out using the RevMan5.3 and STATA12.0 software.Of 1116 citations identified by our search strategy, 14 RCTs met the inclusion criteria. Compared to lumbar fusion, total disc replacement significantly improved ODI, VAS, SF-36, patient satisfaction, overall success, reoperation rate, ODI successful, reduced operation time, shortened duration of hospitalization, decreased postsurgical complications. However, total disc replacement did not show a significant difference regarding blood loss, consumption of analgesics, neurologic success and device success with lumbar fusion. And charges were significantly lower for total disc replacement compared with lumbar fusion in the 1-level patient group, while charges were similar in the 2-level group.Total disc replacement is recommended to alleviate the pain of degenerative lumbar diseases, improve the state of lumbar function and the quality of life of patients, provide a high level of security, have better health economics benefits for 1-level patients. With progressive degeneration, the effectiveness of the nutrition mechanism of the intervertebral disc decreases, in consequence, nucleus pulposus cells lose the ability to produce extracellular matrix proteins and proteoglycan, which results in disc progressive instability and desiccation.Low back pain is a very common symptom. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. And fusion is the primary surgical option to treat disabling mechanical low back pain. Although fusion surgery yields better results in decreasing pain and disability compared to the conservative treatment, it also has detrimental effects on the normal physiological and biomechanical function of the spine.In patients suffering from chronic low back pain caused by lumbar degenerative disc disease, previous studies have shown that surgical treatment is more effective than conservative treatment in relieving low back pain. The mechanism of pain relief is based on the combination of complete discectomy, restoration of segmental load transfer and sagittal balance and motion.,13 Besides, a secondary intention of this technique is the preservation of normal motion at the adjacent lumbar levels, hoping that this will reduce later degeneration of the adjacent lumbar segments. Many clinical trials and follow-up studies of the use of lumbar total disc replacement have shown that total disc replacement is not inferior when compared with the standard spinal fusion procedures.–17 Even more, renewed interest in disc arthroplasty has occurred in USA over the past decades and several groups have published encouraging results..,21 and total disc replacement was more common in younger patients. In addition, several previous meta-analyses have reported on this topic have different opinions on total disc replacement and lumbar fusion for treating lumbar degenerative diseases.,48,49Total disc replacement is another surgical option approved in the mid-2000's for the treatment of lumbar disc herniation.Therefore, it was still uncertain whether total disc replacement was more effective and safer than fusion. The objective of this study was to systematically compare the efficacy and safety of total disc replacement to fusion for the treatment of lumbar degenerative disc diseases.2http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018112661). This article was written using PRISMA reporting guidelines and was based on previously conducted studies. Thus no ethical approval and patient consent are required.The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO registration No.CRD42018112661), available online: 2.1 The literature were retrieved using multiple online databases including PubMed, Web of Science, Embase, the Cochrane Library, Chinese National Knowledge Infrastructure Database (CNKI), Wangfang database, and VIP database, for all years up to October 2018. There were no limits on study dates or any languages, publication types, and status restrictions. The key terms used in these searches were “total disc replacement”, “intervertebral disc replacement”, “artificial disc replacement”, “fusion”, “lumbar degenerative diseases”, “lumbar degeneration”, “spondylolisthesis”, “ lumbar disc herniation”, “lumbar disc protrusion”, “ lumbar spinal stenosis”, “ligamentum flavum hypertrophy”, “ligamenta flava thickening”. Different search strategies were used for Chinese and foreign language databases. In addition, the reference lists of previously published systematic reviews on the subject of total disc replacement versus fusion for lumbar degenerative diseases were manually examined for pertinent studies.As with the original review, we used the search strategies recommended by the Cochrane Back Review Group for the identification of RCTs.2.2The retrieved literature was screened by 2 independent investigators to evaluate eligibility, and any discrepancies were settled by discussion and consensus. First, the titles and abstracts of searched studies were screened. Then, full papers were reviewed to examine whether each study met the following criteria:1.randomized controlled trial;2.types of participants must be patients with symptomatic diagnosed lumbar degenerative diseases;3.studies using total disc replacement and fusion for the treatment of lumbar degenerative diseases.When multiple time points were reported either in one particular report of a study or over the course of several articles from the same study, the longest follow-up period on treatment was considered in our article. If overlapping subject populations were enrolled in different reports, the one of longest follow-up period was selected for inclusion. Full texts of all references were available.2.3The excluded studies were excluded due to the following reasons:1.studies does not conform to the above criteria;2.treatment measures include other methods besides total disc replacement and lumbar fusion;3.studies were in the form of letters, abstracts, reviews, or comments;4.studies were impossible to extract relevant data.2.4The following data were independently extracted by 2 authors: the name of first author, year of publication, country, number of patients under total disc replacement and lumbar fusion, sample size, age, gender of patients, follow-up duration. When relevant data had not been reported, we contacted the authors by email or in other ways to attempt to obtain the missing information.2.5 For each included study, each type of bias was rated as high, low, or unclear and entered into the risk of bias table. 4 review authors, 2 with methodological expertise and 2 with content expertise, independently assessed the risk of bias of the included studies. The review authors resolved any disagreements by discussion, including input from a third independent review author if required.We assessed the risk of bias of RCTs in this review using the Cochrane Collaboration Risk of Bias Tool. And risk of bias was assessed according to the Cochrane Handbook.2.6Visual analog scale (VAS) and Oswestry disability index (ODI) were the main outcomes, and the secondary outcomes were operation time, duration of hospitalization, blood loss, complications, patient satisfaction, work status, over successful, reoperation rate, ODI successful, device successful, and consumption of analgesics.2.7 The judgments were based on risk of bias, inconsistency, indirectness, imprecision, and publication bias. We operated on this web page: https://gradepro.org/.The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was used to assess the quality of the evidence for each outcome of meta-analysis. Levels of quality of evidence recommended by the GRADE Working Group were defined as high (++++), moderate (+++), low (++), and very low (+).2.82 statistic. An if P ≤ .1 and I2 ≥ 50% signified the possibility of statistical heterogeneity, and the random-effects model was chosen for the computation of MD or SMD with its corresponding 95% CI. Otherwise, no obvious heterogeneity (P > .1 and I2 < 50%) was considered to have occurred in the included studies, and the fixed-effects model was selected to generate the MD or SMD with its corresponding 95% CI. The forest plot for each parameter was constructed to illustrate the weight ratio of each incorporated study. All statistical analyses were carried out using the RevMan5.3 and STATA12.0 software. And the significance threshold was a 2-sided P < .05.The outcomes of interest include dichotomous data and continuous variables. Dichotomous data were expressed as the risk ratio (RR) and mean difference (MD) was used to assess the difference in the continuous outcomes between the groups. Also, standardized mean difference (SMD) was chosen if clinical outcome was the same but measured using different methods in the different trials. Its corresponding 95% confidence interval (CI) for each parameter was computed in total disc replacement-treated versus fusion-treated. Statistical heterogeneity across included studies was examined by the Q test and I33.1–35,44 were included in the systematic review.The search results are displayed in Figure  was published in French and the rest were published in English. In this systematic review, a total of 1890 participants with lumbar degenerative diseases were involved. The trial sample size ranged from 32 to 577 participants. The type of artificial disc is one of 5 following devices: CHSRITE, ProDisc-L, ProDisc-II, MAVERICK and FlexiCore. And the control group included anterior fusion, posterior fusion and circumferential fusion. The intervention period is reported between 6 months to 5 years. Baseline imbalance was not found in the demographic characteristics or the outcomes between the study groups.The characteristics of the included trials are summarized in Table ,31,33–35 indicated “randomly allocating”. Five trials–25,32,33 mentioned it use the blind method of participants. Twelve trials–34 reported participant losses. Four trials,32,34,35 have clinical trial registration. Selective reporting for other studies was difficult to assess, and trial protocols were unavailable. Ten studies–30,32–35 found no significant other bias.Figure 3.23.2.1–33,35 Among these, 4 articles,24,29,30 were reported at different stages of the same study, both of which had a record of VAS, and selected Skold et al and Zigler et al study with long follow-up were used for analysis. Besides, 5 references–28,31,33 data cannot be completely extracted, so the results can only be displayed in method of description. So 5 studies,30,32,35 are included in the meta-analysis. The insignificant heterogeneity between trials was observed , and therefore a fixed-effects model was used for statistical analysis . Results from the pooled analysis indicated that there was a significant differences in improving VAS in favor of the total disc replacement . In the study of Blumenthal et al, At 6 weeks, 3 months, 6 months and 12 months after surgery, disc replacement was more effective than spinal fusion in relieving pain symptoms, but 24 months later, there was no significant difference between the 2 methods. And there was no statistical difference between this 2 groups in terms of VAS at 5-year postoperative time point in Guyer study. Zigler et al result was although mean total disc replacement VAS scores were less than the fusion scores at each follow-up period, differences were not statistically significant. Sasso observed total disc replacement delivered improvements in pain similar to fusion. At last, Delamarter et al study found patients who received a disc replacement had a significant decrease in VAS score as early as 6 weeks and 3 months compared with fusion patients. However, the disc replacement patients continued to show more improvement than fusion patients, the difference was not significant.VAS was report in 12 studies.3.2.2–33,35 reported ODI as an outcome in the groups, similar to the outcome indicator --VAS, as for articles for different stages of the same study, Skold study and Zigler study were selected to analysis due to the long follow-up periods. Also, 5 studies,28,31,33 were reviewed owing to these data cannot be completely extracted. So the rest studies,30,32,35 were analyzed and the insignificant heterogeneity between trials was observed , and therefore a fixed-effects model was used for statistical analysis . Results from the pooled analysis indicated that there was a significant differences in improving VAS in favor of the total disc replacement . In the study of Blumenthal et al, ODI of the disc replacement group improved better than that of the lumbar fusion group after operation, but after 24 months, there was no significant difference between the two groups. Guyer et al study demonstrated there are no statistical difference between the groups in terms of ODI scores at the 2 and 5-year postoperative time points. Similar results with the VAS results, the total disc replacement ODI scores were less than the fusion scores at each follow-up period, the difference was statistically significant only at 3-month follow-up in Zigler study. Sasso et al observed total disc replacement delivered improvements in ODI scores similar to lumbar fusion. Delamarter et al yielded the result that disc replacement patients had significantly more reduction as early as 3 months, at 6 months and later up to 2 years, disc replacement and fusion patients had similar scores on ODI.Twelve trials3.2.3,30,32,35 were included, Berg et al and Skold et al studies had the same intraoperative data, so meta-analysis included only Berg findings. For the same reason, in the studies of Zigle et al and Zigle et al, the result of Zigle et al was chosen. Also, Blumenthal et al and Guyeret et al are different stages of the same study, Guyeret study was selected to analysis due to the long follow-up periods. Zigle et al research lacks of standard deviation, so data cannot be extracted for meta-analysis, and the results are displayed in Table ,27,29,32 were analyzed. First, in term of operation time, these trials exhibited significant heterogeneity , as shown in Figure S3. And accordingly, a random-effects model was used for statistical analysis. The meta=analysis of 5 trials revealed that total disc replacement group have a statistically significant decrease in operation time . Second, in regard to comparison of the bleeding volume, there is no difference between the 2 methods of operation . Third, There was statistically significant difference between the total disc replacement therapy and lumbar fusion therapy in duration of hospitalization. The meta-analysis from the 5 independent trials revealed total disc replacement can significant reduce hospital stay .(1)The intraoperative conditions, including operation time, blood loss, duration of hospitalization, was shown in Figure S3,S4,S5, the results of the 9 trials3.2.4,25,30,32 Berg et al and Skold et al studies belong to the same randomized controlled trial. So Skold study was analyzed. The insignificant heterogeneity between trials was observed , and therefore a fixed-effects model was used for statistical analysis . The meta analysis from the 4 independent trials demonstrated that participants treated with total disc replacement therapy improving more significantly than participants treated with lumbar fusion therapy .SF-36 was report in 5 studies.3.2.5,26,30,32 that documented consumption of analgesics, as shown in Figure S7. These trials exhibited significant heterogeneity . And accordingly, a random-effects model was used for statistical analysis. The meta-analysis of 4 trials revealed that there are not statistically significant in consumption of analgesics .Of the 4 trials3.2.6,30,32,35 were included, Berg et al and Skold et al studies were the same trials, so meta-analysis included only Skold findings due to the long follow-up periods. Thus, the results revealed a significant difference in participants treated with total disc replacement and those treated with lumbar fusion, with total disc replacement therapy being favored .Data regarding the patient satisfaction are shown in Figure S8. The results of 7 trials3.2.7,30,32,35 used work status as an outcome. The same reason as before, Skold study, Guyer study and Zigler et al with long follow-up were used for analysis rather than Berg study, Blumenthal study and Zigler study. Significant heterogeneity between trials was observed , so a rand-effects model was used for statistical analysis. However, there was no significant difference in work status between total disc replacement and lumbar fusion  .Nine trials3.2.8,27,32,35 reported over success as an outcome. And Guyer et al and Blumenthal et al studies were the same trials, so meta-analysis included only Guyer result due to the long follow-up periods. Hence, pooled analysis indicated that over success improved significantly more in the total disc replacement group than lumbar fusion .A comparison of over success is shown in Figure S10. Five studies3.2.9,26,27,32 appear in Figure S11. Same as before, the meta-analysis included only Guyer result instead of Blumenthal et al finding due to the long follow-up periods. And comparisons of neurologic success with total disc replacement and lumbar fusion displayed insignificant heterogeneity  between studies. Thus, a fixed-effects model was used for analysis and there was no statistical difference between 2 methods for neurologic success variations , although this has a tendency to benefit the total disc replacement group.Neurologic success data from 4 trials3.2.10,30,32,34 assessed the incidence of reoperation of total disc replacement in comparison with lumbar fusion. Due to some articles are different stages of the same study, Berg study and Zigler study were not to be analyzed due to the short follow-up periods. Thus, meta-analysis showed that there was a significant difference found in favor of the total disc replacement  .Seven trials3.2.11,26,27,35 reported ODI success, but Berg study and Blumenthal study were not to be analyzed due to the repetition with Skold study and Guyer study. So, the rest studies were analyzed and a fixed-effects model was used for statistical analysis according to the low heterogeneity . The results displayed that significant differences in favor of the total disc replacement  .Six studies3.2.12,27,30 eligible for this analysis. The meta-analysis included only Guyer result instead of Blumenthal et al finding due to the long follow-up periods. And a small degree of heterogeneity was found in the analysis , thus, a fixed-effects model was selected for construction of forest plots. And the results indicated that no significant difference was detected in device success  , although this has a tendency to benefit the total disc replacement.With regard to the device success, there were 3 studies3.2.13–26,29–32 for this analysis . For the same study, only the longest follow-up trial was selected. So Skold study and Zigler et al were included in the analysis. Thus, the meta analysis from the 6 independent trials demonstrated that participants treated with lumbar fusion therapy leading to more complications than participants treated with total disc replacement therapy .In term of complications, there were 8 eligible studies3.2.14 makes charge analysis. A total of 53 patients were included in the study, including 36 in total disc replacement group and 17 in fusion group. For patients with 1-level disease, the charge analysis shows significant difference between total disc replacement and fusion group. The mean total charge for the total disc replacement group was $35,592 versus $46,280 for the fusion group (P = .0018). For patients with 2-level disease, the charge analysis shows no significant difference between total disc replacement group and fusion group. As shown in the Table P = .55).Of 14 studies, only 1 study3.2.15P = .019) had a certain publication bias by using Egger regression test.The funnel plot of each meta-analysis is provided in Appendix S2. We found that only this outcome of device success  and acquired spinal instability. However, these complications can be effectively avoided by performing a total disc replacement surgery, as an alternative technique, which is made up of bearing surfaces designed to accommodate load without breaking, to reduce friction and wear and to keep range of motion as long as possible.–41Lumbar degenerative disease is essentially characterized by lumbar or/and leg pain with or without walking difficulties due to some specific situations, such as narrowing of spinal canal, prominent discs, degenerative disc disease, arthropathy and spondylolisthesis.,42,43 These factors also contribute to improving the functional status of the lumbar spine for patients who treated by total disc replacement operation. Moreover, with regard to consumption of analgesics, neurologic success and device success, our meta-analysis results indicated that no significant difference was detected between 2 operative methods. As we all know, the main purpose of narcotic use is to relieve the pain of the incision after operation, so the degree of incision pain may be similar between the two surgical methods. Also, Since both methods improve the symptoms of lumbar spinal stenosis, this may explain that there is no difference in the effect of the 2 treatments on nerve function. At last, device success was defined as the absence of any need for reoperation to modify or remove implants and no need for additional fixation. As shown in Figure S14, there is a tendency to benefit for the total disc replacement. The result of no difference between 2 methods for device success may be that few papers (only 2 papers) were included, and more research is needed to clarify this result. As for charge analysis, it shows significant difference between total disc replacement and fusion group for patients with 1-level disease, but insignificant difference for patients with 2-level disease. So, chargers with total disc replacement are significantly low compared with lumbar fusion in the 1-level patients.Our systematic review and meta-analysis found that disc replacement is superior to lumbar fusion in many respects, including ODI, VAS, SF-36, patient satisfaction, overall success, reoperation rate, ODI successful. In addition, postoperative complications of disc replacement surgery are also less than lumbar fusion. Therefore, the superiority of total disc replacement over lumbar fusion may be partially explained by the relatively simple surgical procedure and decreased postsurgical complications in the disc replacement group. As is known to us all, disc replacement surgery is usually done through anterior approach. However, lumbar fusion still requires bone grafting from other body parts or the use of allogeneic bone for interbody or posterolateral fusion. Thus, this adds a lot of surgical procedures. In particular, if a combined anterior and posterior lumbar fusion surgery is performed, more surgical steps are needed. So, as for intraoperative conditions, total disc replacement can significant reduce operation time and hospital stay. Although there is no difference for bleeding volume between the two methods of operation, the trend of bleeding volume of lumbar disc replacement surgery is less than that of lumbar fusion surgery is very obvious. The operation of intervertebral disc replacement is simple, so there are fewer complications after operation, so the clinical effect after operation is more remarkable. Meanwhile, less hospital stay is available. Besides, the device of total disc replacement is designed in a motion preservation technology. So the use of lumbar disc replacement in anticipation of minimizing the development of adjacent segment disease.Several previous meta-analyses which can be retrieved have reported on the same topic Table . CompareThe present meta-analysis has the following limitations. First, some outcome indicators have significant heterogeneity, and we speculated that heterogeneity may come from these risk factors, such as different patient groups, different devices, different fixed tools, and various clinical settings, especially different medical centers and different surgical and anesthetic techniques. However, subgroup analysis cannot be performed because some outcomes just contain 2 to 3 literature. Second, because total disc replacement and lumbar fusion are the obvious operational manipulation, it could be difficultly blinded for doctors, this may lead to unavoidable performance bias. Third, some of articles failed to provide sufficient data, although we made an effect to obtain, including attempting to contact to correspondence author of articles.5This systematic review and meta-analysis suggests that total disc replacement surgery, compared to lumbar fusion surgery, significantly improved ODI, VAS, SF-36, patient satisfaction, overall success, reoperation rate, ODI successful, reduced operation time, shortened duration of hospitalization, decreased postsurgical complications. However, total disc replacement did not show a significant difference in terms of blood loss, consumption of analgesics, neurologic success and device success with lumbar fusion. And charges were significantly lower for total disc replacement compared with lumbar fusion in the 1-level patient group, while charges were similar in the 2-level group. Hence, total disc replacement is recommended to alleviate the pain of degenerative lumbar diseases, improve the state of lumbar function and the quality of life of patients, and provide a high level of security. Moreover, total disc replacement has better health economics benefits for 1-level patients.Data curation: Long Liang, Bing-bing Zhang.Formal analysis: Long Liang, Bing-bing Zhang.Investigation: Tao Zhu.Methodology: Hai-jun Zhang, Zhi-guo Yuan, Tao Zhu.Software: Hai-jun Zhang, Tao Zhu.Supervision: Zhi-guo Yuan, Yanfei Chen.Validation: Tao Zhu.Writing – original draft: Dengyan Bai.