Although percutaneous endoscopic lumbar discectomy (PELD) has shown favorable outcomes in the majority of lumbar discectomy cases, there were also some failures. The most common cause of failure is the incomplete removal of disc fragments. The skin entry point for the guide-needle trajectory and the optimal placement of the working sleeve are largely blind, which might lead to the inadequate removal of disc fragments. The objective of this study was to present our early experiences with image-guided PELD using a specially designed fluoroscope with magnetic resonance imaging-equipped operative suite (XMR) for the treatment of lumbar disc herniation.This prospective study included 89 patients who had undergone PELD via the transforaminal approach using an XMR protocol. Pre- and postoperative examinations (at 12 weeks) included a detailed clinical history, visual analogue scale (VAS), Oswestry disability index (ODI), and radiological workups. The results were categorized as excellent, good, fair, and poor according to MacNab's criteria. At the final follow-up, the minimum follow-up time for the subjects was 2 years. The need for revision surgeries and postoperative complications were noted on follow-up.n = 2) and recurrent disc herniation (n = 2).Postoperative mean ODI decreased from 67.4% to 5.61%. Mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR had shown remnant fragments after the first stage. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25) poor results. Four (4.49%) patients had remnant disc fragments on XMR, which were removed during the same procedure. All of these patients had either highly migrated or sequestrated disc fragments preoperatively. Four (4.49%) other patients needed a second, open surgery due to symptomatic postoperative hematoma (This prospective analysis indicates that XMR-assisted PELD provides a precise skin entry point. It also confirms that decompression occurs intraoperatively, which negates the need for a separate surgery and thus increases the success rate of PELD, particularly in highly migrated or sequestrated discs. However, further extensive experience is required to confirm the advantages and feasibility of PELD in terms of cost effectiveness. Traditional open lumbar laminectomy and discectomy were modified to a more recent microlumbar discectomy technique, which is a less-invasive procedure for the treatment of lumbar disc herniation. However, this method has potential disadvantages, such as paraspinal muscle damage, iatrogenic instability, epidural fibrosis, a higher probability of retraction injuries to neural tissue, and disc space collapse leading to facet arthropathy –5]. Wit. Wit5]. With the increasing interest in PELD, some of its limitations have been discussed in the literature. A major concern with PELD is the risk that revision surgery will be required due to the possibility of remnant disc fragments postoperatively  and alsoWe received an Ethical Committee  approval for this study prior to commencing it. We prospectively evaluated 89 consecutive patients who underwent XMR-assisted PELD. The subjects included 30 women and 59 men with an average age of 46.6 years. The inclusion criteria were as follows: (1) lower limb radiculopathy; (2) presence of root tension signs ; (3) failure of adequate (6 weeks) and supervised conservative treatment with lifestyle modifications, nerve root/epidural blocks, nonsteroidal antiinflammatory drugs, and physiotherapy ; and (4) corroborative clinical and radiological findings. Patients with (1) cauda equina syndrome, (2) severe central canal stenosis, and (3) associated segmental instability were excluded from the study.All patients were evaluated preoperatively by detailed clinical history, physical examination, visual analogue scale (VAS) for back and leg pain, Oswestry disability index (ODI), and radiological imaging . We have installed a new system that integrates X-ray and MR imaging (an XMR suite) with a table  that can slide from the MR to the fluoroscope suite and vice versa. This permits rapid, smooth, intermodality patient transport by trained operation theater staff Figure  in the XOnce the PELD procedure was finished, the scope was removed, and a sterile plastic tube was placed with a sterile adhesive over the wound to avoid a new entry point for the guide wire if further surgery was planned. The patient (without changing the operating position) was shifted on the operating table back to the MR for an intraoperative MR scan to check the adequacy of the decompression. If any remnant fragments were found at this stage Figure , the patAll patients were followed up at 12 weeks by telephonic interview, mailed questionnaire, or hospital follow-up. The postoperative VAS score and ODI were charted. The results were categorized as excellent, good, fair, and poor based on MacNab's criteria. MacNab's criteria were measured as follows: ‘excellent’ is a state without pain, without restriction of movement, and would allow the patient to function normally; ‘good’ is a state with occasional pain but which would allow the patient to function normally; ‘fair’ indicates slight progress; and ‘poor’ reflects no progress. The same evaluation was done at the final follow-up, with a minimum follow-up of 2 years.The mean duration for back and leg pain was 156.8 and 18 weeks, respectively. Eight, 19, 49, and 13 patients had disc herniation at the L2-3, L3-4, L4-5, and L5-S1 levels, respectively, on MRI, which correlated with clinical findings. Out of 89 patients who underwent preoperative XMR as part of the protocol, seven showed a change in disc size and/or location, as compared to previous imaging studies. The mean operative time for transforaminal PELD was 60 min.n = 2) and reappearance of symptoms during the first 2 weeks after the primary procedure (n = 2). These four patients underwent a separate open surgery; two had a symptomatic hematoma and the other two had true recurrent disc herniation within 2 weeks of the first surgery. Besides these cases, there were no other intraoperative or postoperative complications or infections up until the latest follow-up. Furthermore, the patients' VAS for back and leg pain and ODI were maintained at the final follow-up compared with postoperative scores.The postoperative mean ODI decreased from 67.4% (preoperative) to 5.61% (postoperative), and the mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR due to remnant fragments after the first stage. All of these fragments were diagnosed preoperatively either as a highly migrated or sequestrated disc. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25%) poor results. Four (4.49%) more patients required a separate, second surgery due to persistent symptoms even after complete fragment removal had been confirmed using XMR . There was no significant difference in the failure rate between the nonmigrated herniation and low-grade migration groups . However, the HGM group  showed a significantly high incidence of failure . Based on these results, Lee et al. concluded that open surgery may be considered for herniation with HCC and/or HGM. Schaffer and Kambin [As reported by Lee et al. , the maid Kambin  analyzedThe distribution of patients with HCC and HGM in our series was 22.47% and 21.35%, respectively, which was comparatively higher than that in Lee et al.   patients underwent a second subsequent open surgery despite confirmed decompression on postoperative XMR. Out of the four patients, two had persistent symptoms after PELD due to postoperative hematoma Figure , and theHowever, there are certain disadvantages of the XMR system. It increases the cost of the procedure, the inventories are expensive, and it requires trained and supportive staff. Additionally, there is of course a slight increase in the time a patient has to stay in the operating room. However, although the cost of the surgery is a little higher, the XMR system definitely avoids a high dissatisfaction rate after the surgery, especially in the cases of HCC and HGM discs. Moreover, nowadays, we are selectively using XMR-assisted PELD only for patients with highly migrated or sequestrated discs. Of course, patients should be given the choice after informing them of the advantages and disadvantages of the procedures, including the extra expense. However, from our experience, most patients choose XMR, showing that satisfaction and complete removal are more important factors for them than the cost of the procedure. Although there is no absolute contraindication of this technique for canal stenosis or other types of disc herniation, we emphasized using this technique in HCC and HGM discs not to miss the remnant disc fragments and to optimize the cost effectiveness of the procedure. Another factor is the use of antibiotics in our study. As this was our first experience with the XMR, which takes an extra 20 to 30 min to shift the patient to the MR suite, we followed the protocol by prescribing 6 days of extra oral antibiotics as a precautionary measure. However, we agree that this is not required, and we now give only one shot of preoperative intravenous antibiotics.The present prospective analysis indicates that XMR-assisted PELD can be performed with a precise skin entry point. Furthermore, it confirms decompression intraoperatively, thereby reducing the need for a separate, second surgery and increasing the success rate of PELD. However, it should be used in selected cases with high-grade migrated or sequestrated disc herniations.The authors declare that they no competing interests.Authors GC, SHL, and HNM participated in the study design and approving the work; NP, TJA, SHM, and MSG participated in the data collection; HNM and NP participated in the manuscript writing and data analysis; and GC, SHL, and TJA participated in the final revision and approval. All authors read and approved the final manuscript.


Objectives: To investigate the quality of newly formed bone in sheep mandibles submitted to distraction osteogenesisand low-level laser therapy (LLLT), based on hardness and modulus of elasticity values. The ideal moment for laser application (during the latency/activation period vs. during the bone consolidation period) was also evaluated.Computed tomography imaging was used to assess relapse as a result of early device removal.Study design: Extraoral distraction devices were placed in five sheep so as to achieve 1.5 cm of lengthened bone in 60 days. Distraction devices were removed 50, 40, and 33 days after surgery. Four animals were treated with LLLT, at different times, and one was used as control (no LLLT).Results: When applied during the bone consolidation period, LLLT caused an increase in hardness and modulus of elasticity values. On the other hand, animals irradiated with LLLT during the latency/activation period presented a delay in bone healing. A period of consolidation of 13 days  was associated with relapse.Conclusions: Nanoindentation tests were able to detect slight abnormalities in bone metabolism and proved to be important tools for the assessment of bone quality following distraction osteogenesis. LLLT provided increased benefits when applied during the bone consolidation period, once it promoted an increase in hardness and modulus of elasticity values. According to our results, the bone consolidation period should be of at least 3 weeks, so as to prevent relapse. Key words: Osteogenesis distraction, low-level laser therapy, elastic modulus, hardness tests. Distraction osteogenesis has become an increasingly consolidated alternative method for facial bone reconstruction, with promising results. It can be used to correct congenital defects, defects caused by trauma, after oncological surgeries and for the oral rehabilitation of patients with osteointegrated implants. However, the long-term stability of results obtained with distraction osteogenesis is not well documented, and reports of instability and relapse can be found in the literature . TherefoIn this sense, low-level laser therapy (LLLT) is a procedure that uses large portions of the visible and infrared light spectra to improve the healing process by stimulating vascularization, fibroblast proliferation and the deposition of collagen ,3. The eMiloro et al.  have conNew bone formation can be assessed using several tests, of variable complexity and accuracy. Nanoindentation tests are able to reveal physical properties such as hardness, apparent modulus of elasticity, defects, and residual stresses in the areas analyzed . Among tThe objective of the present study was to assess the quality of newly formed bone in sheep mandibles submitted to distraction osteogenesis and LLLT, based on hardness and modulus of elasticity values. In addition, the present study aimed to assess the ideal moment for laser application, whether during the latency/activation period or during the bone consolidation period. Finally, the study also assessed relapse after early device removal, based on computed tomography (CT) findings. The present research protocol was approved by the Research Ethics Committee at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. Five female Corriedale sheep, aged 2 years and weighing 40-45 kg, were included in the investigation following basic laboratory tests conducted to discard the possible presence of any diseases prior to surgery that could interfere with the study results.The animals  were submitted to the same distraction osteogenesis protocol and assessed for a period of 60 days. In sheep A, the distraction device was used for 50 days, in sheep B for 40 days, and in sheep C, D, and E for 33 days. LLLT employed the same parameters in all sheep, and was applied during the latency/activation period in animals A, B, and C, and during the bone consolidation period in sheep D; sheep E was not submitted to LLLT. Throughout the study period, the animals were housed in pairs, in appropriate cages, at the animal hospital of Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. Each animal was identified with a plate displaying the corresponding letter. Anesthesia procedures were carried out by a veterinarian involved in all phases of the study, both prior to surgery, during the procedures, and after surgery. General anesthesia was induced with acepromazine 0.05 mg/kg, meperidine 2 mg/kg, ketamine 4 mg/kg, and halothane mask. Propofol 8 mL was used during intubation. Anesthesia was maintained with halothane in 100% oxygen (O2). Additional, maintenance intramuscular doses were administered as necessary. Antibiotic prophylaxis was performed with intravenous administration of ampicillin sodium 10 mg/kg.Surgery was then initiated, as follows: trichotomy of the left submandibular region, antisepsis, local infiltration of 3 mL of 1% lidocaine and epinephrine 1:100.000, and incision (Risdon type) 1 cm below the left basilar region of the mandible, measuring approximately 3 cm. Using a layered approach, tissues were separated through both the lateral and medial faces of the mandible by blunt dissection using Metzenbaum scissors and detachers. Farabeuf retractors were positioned to expose the lateral surface of the mandible. Corticotomies were performed with a reciprocating saw through the medial and lateral faces of the mandible, in the mandibular angle region. The distraction device was fixed with four transcutaneous screws under irrigation with saline solution. Distractors were then activated until encountering resistance, and fractures were produced with straight chisels. The surgical wound was closed in layers with single interrupted sutures using 4.0 monofilament nylon . After surgery, the sheep remained in the animal hospital and received morphine 0.4 mg/kg every 8 hours for a total of 72 hours, in addition to pentabiotics  every 24 hours, for 7 days. The device used in laser irradiation was Thera Laser®  with gallium-aluminum-arsenide (GaAlAs) active medium, wavelength of 830 ηm (infrared), properly calibrated. The sheep received laser doses directly on the distraction site, at three points across the osteotomy area, with 5 J/cm2 applied to each point, totaling 15 J/cm2, with a power of 50 mW, in a continuous wave mode, for 1.41 minutes. The total energy applied at the end of the experiment amounted to 120 J/cm2. In sheep A, B, and C, submitted to LLLT during the latency/activation period, irradiation was first applied immediately after closure of the surgical wound and then every 48 hours, at a total of eight sessions. In sheep D, submitted to LLLT during the bone consolidation period, the first irradiation session took place after the last activation, and then every 48 hours, also at a total of eight sessions. Sheep E (control) was not submitted to LLLT. Because laser therapy is painless, no sedation or anesthetics were necessary.  -Distraction osteogenesis protocol Latency period – 5 days (days 1 to 5): the distraction device was not activated; it was only inspected and cleaned with 1% iodophor alcohol.  Activation period – 15 days (days 6 to 20): device activation started on the sixth postoperative day at a rate of 1 mm per day, to a total of 15 mm at the end of the activation period. Bone consolidation period – 13 to 30 days : after the activation period, the distractor remained in sheep A for 30 days, in sheep B for 20 days, and in sheep C, D, and E for 13 days, working as a rigid fixation device, so that bone maturation was achieved. Following the bone consolidation period assigned to each animal, distractor removal was carried out under local anesthesia.Sixty days after surgery, all five animals were killed under deep anesthesia, due to cardiorespiratory arrest, as recommended by the Universal Declaration on Animal Welfare. Once death was confirmed by the absence of vital signs, mandibles were dissected and stored in glutaraldehyde, and subsequently submitted to CT imaging. Images were prepared and analyzed in the Laboratory of Materials and Nanosciences, Study Group on Properties of Surfaces and Interfaces, Center for Physics Research and Development, School of Physics, PUCRS .The amount of lengthened bone was assessed using CT images obtained with a Somaton Plus 4 scanner . Samples were positioned so as to allow the production of axial 0.5 mm-thick sections. The PixWiwer® software  was used for image manipulation and for the production of three-dimensional maximal intensity projection (MIP) reconstructions Fig. .A.MIP images were used to measure the bone gap, as a linear measure between the edges of mature bone . Two examiners were responsible for the measurements obtained in each reconstruction, in both axial and coronal directions Fig .B.In order to compare the influence of time of device use on the quality of newly formed bone, the following total times were allowed for each animal: sheep A, 50 days; sheep B, 40 days; and sheep C, D, and E, 33 days. Following CT, the mandibles of each animal were sectioned in two halves, the operated side and the control side (non-operated). Specimens were embedded in acrylic resin and sectioned in axial direction in three blocks using a band saw. All blocks were properly identified as control or operated side, and as upper, middle or lower portion.In order to obtain perfectly plane and polished surfaces, as demanded by the nanoindentatoin tests employed, bone blocks were submitted to a polishing sequence using eight water-cooled sandpapers ; at each interval (sandpaper change), specimens were immersed in fully deionized water, using an ultrasound device, for approximately 5 minutes. Specimens were polished with sandpapers 600, 1200, 2400, and 4000 using a 1:1 mixture of propylene glycol and isopropyl alcohol, and dried with nitrogen gas. At the end of the polishing process, specimens were finished with 9 μm, 1 μm, and 1/4 μm diamond polishing paste , and finally with silica carbonate solution and water using a metallographic polishing machine  at 50 x magnification in order to identify the elongated bone area and to define the regions to be assessed. The photomicrographs obtained were marked with red circles indicating reference points, i.e., regions to be measured in the nanoindentation tests, always on the external cortical bone Fig..A, B. ThThe macroscopic analysis carried out during mandible dissection revealed the presence of a bone callus in the distracted region of all specimens, with different degrees of mineralization on the cortical bone Fig. .CT images were used to measure the distracted bone region and to assess the influence of early device removal on bone expansion results. The three-dimensional MIP images showed differences in bone density, with a distraction distance (gap) of 14.9 mm for sheep A and 13.7 mm for sheep B. Sheep C, D, and E, submitted to only 13 days of bone consolidation, presented relapse, with a mean gap of 9.9 mm, 9.9 mm, and 8.8 mm, respectively.Tables 1 and 2 show mean and standard deviation obtained for nanohardness and modulus of elasticity in each specimen, on both the operated and control sides, as a result of the different distraction and LLLT protocols employed. The application of LLLT during the bone consolidation period caused an increase in hardness and modulus of elasticity values, compared to a delay in bone healing in specimens submitted to LLLT during the latency/activation period.The distraction osteogenesis protocol adopted in the present study, namely, a latency period of 5 days and device activation once a day at 1 mm/day, is widely used and consolidated in the literature -12. The Postoperative time and the decision to keep animals alive for 60 days was based on the need for a minimum amount of time to allow the assessment of relapses. Moreover, several previous studies had already adopted the same period of 60 days to assess bone healing, e.g. Friesen et al.  and PinhDistraction osteogenesis involves metabolic activities that are potentially biomodulated by the use of laser. Therefore, laser therapy is believed to accelerate the healing process in newly formed bone, thus reducing the overall treatment time.Current developments of the distraction osteogenesis technique lie essentially in removing the distractor as early as possible, whenever bone quality and dimensional stability are observed. In our study, sheep A used the inactivated distractor for 30 days, and the CT images revealed relapse, with a contraction of 0.1 mm in the distracted area in that animal. Sheep B showed slight dimensional instability after 20 days of bone consolidation, with a contraction of 1.3 mm in the distracted bone area (gap of 13.7 mm on CT). This difference observed in sheep B, however, might be the result of a bias in the distraction technique, once activations were performed manually. On the other hand, sheep C, D, and E, in which the bone consolidation period was significantly reduced to only 13 days, as a result of early device removal, showed a contraction of 5-6 mm in the distracted area. In addition, all three animals submitted to a bone consolidation period of 13 days, either treated with laser or not, presented relapse. These findings are in agreement with other published studies , 16, whiThe present study showed that laser application yielded positive results when applied during the bone consolidation period. On the other hand, when applied during the latency and activation period, laser therapy caused a decrease in hardness and modulus of elasticity values, with a consequent delay in bone calcification.The results obtained in sheep D (LLLT applied during the bone consolidation period), namely hardness of 414.4 MPa and modulus of elasticity of 12.3 GPa , are comSheep E (control) was not submitted to LLLT. Although this sheep had a shorter bone consolidation period when compared with sheep A and B, the physical properties observed in the mandible of sheep E were higher than those observed for all sheep treated with LLLT during the activation period. The lowest modulus of elasticity and hardness results were found in sheep C, which used the distractor for 33 days and was submitted to LLLT in the activation period. These findings may suggest that the application of LLLT during the activation period in fact provokes a delay in bone healing, a hypothesis that is reinforced by the marked presence of cartilage tissue and endochondral ossification observed in specimens irradiated with LLLT during the activation period, as proposed by Cerqueira et al. .Although the use of distraction osteogenesis has become increasingly common, it can cause significant discomfort to the patient, especially when external devices are used, possibly leading to infections, paresthesia, hypertrophic scars and social difficulties . TherefoLLLT provided increased benefits when applied during the bone consolidation period, with relevant increases in hardness and modulus of elasticity values. A bone consolidation period of at least 3 weeks should be allowed so as to prevent relapse. Table 2


P-trend <0.01). The correlated factors for cognitive impairment, depression, and comorbidity of the two conditions were similar, and employment status and years of schooling were associated with all three conditions.This study was conducted to investigate the prevalence of cognitive impairment, depression, and comorbidity of the two conditions and related factors in subjects aged in early 60s. This cross-sectional study included 3,174 inhabitants aged 60–64 years old in a rural area of Korea. Cognitive function was evaluated by the Korean version of the Mini-Mental State Examination (MMSE-K), and depression was measured using the short form of the Geriatric Depression Scale (GDS-15). The overall prevalence of cognitive impairment (MMSE-K≤24) was 17.4%, that of depression was 26.0% (GDS-15≥8), and the co-morbidity was 7.1%. Female gender, living with one housemate, and high GDS-15 score were significantly associated with increased cognitive impairment. Employment status and more years of schooling were associated with a decreased probability of cognitive impairment. Increased depression was significantly associated with bereavement and receiving benefits from the Medical Aid Program. Employed status, more years of schooling, and higher MMSE-K scores were significantly associated with decreased depression. The risk of comorbidity was associated with bereavement and receipt of Medical Aid benefits . Employment and more years of schooling were associated with a lower risk of comorbidity (OR, 0.46; 95% CI, 0.34–0.62,  The proportion of the world’s population in older ages continues to rise because mortality is delayed in the elderly and fertility remains low. Thus, geriatric mental health is emerging as a major health problem. Cognitive impairment and depression are major mental health problems affecting older people Although most developed countries have accepted that attainment of a chronological age of 65 years renders a person “elderly” or older, the United Nations uses a cutoff of 60 years. However, most studies of the prevalence of cognitive impairment, depression, and their associated factors have targeted people aged ≥65 years. Aging is a gradual progression and there is no distinct demarcation at age 65 years but studies on cognitive impairment and depression focusing on subjects aged in their early 60s are rare. Only a few studies have targeted the mental health of subjects aged in their early 60s (60–64 years) Therefore, in this study, we investigated the prevalence of cognitive impairment and depression and related factors in subjects aged in their early 60s living in a rural area of Korea. We also investigated the factors associated with the comorbidity of cognitive impairment and depression through an exploratory study.2 and had 144,487 residents at the end of 1999. Of the 5,015 people aged 60–64 years identified through the national resident registration list, 1,222 were excluded. Among those excluded, 784 had moved outside the city before the study started, 34 were institutionalized, 13 had unknown addresses, and 391 were ineligible due to inaccurate birth-date records. Face-to-face interviews were conducted by trained medical doctors and students. The subjects were given full information about the survey, and those who agreed to participate were interviewed. Among the 3,793 eligible in the population, 402 refused to participate, 191 were absent for all of the three visits, and 26 could not participate due to medical conditions. Of the latter, 21 were hospitalized with acute diseases, 3 were deaf, and 2 had aphasia. Thus, 3,174 people participated in the study, for an overall response rate of 83.7%. We additionally excluded 133 participants who did not complete both tests for cognitive function and depressive symptoms, so data of 3,041 participants were finally analyzed.Participants in this study were recruited from all inhabitants aged 60–64 years living in Dalseong County, a rural area located in Deagu, South Korea. This area covers 426.92 kmCognitive function was evaluated by the Korean version of the Mini-Mental State Examination (MMSE-K). The instrument was developed to assess cognitive function in older Koreans and scores were adjusted to consider educational level as suggested by Park et al This study was approved by the institutional review board of the Catholic University of Deagu Medical Center. All participants provide verbal informed consent because nearly 35% were never educated and 22% were illiterate, therefore to obtain written consent form from all participants was impossible. Also we considered that it took nearly half hour to finish measurements and those who completed agreed to participate with their own will. The institutional review board of the Catholic University of Deagu Medical Center approved this consent procedure.Characteristics of the study participants are presented as numbers and proportions, and means and standard deviations of the corresponding MMSE-K and the GDS-15 scores were calculated. Also, we calculated Pearson’s correlation coefficient between MMSE-K and GDS-15 scores. Factors associated with cognitive impairment and depression were initially investigated using univariate analysis. Multivariate logistic regression followed, after adjustment of all variables included in univariate analysis. The independent variables included in analysis were gender, marital status, number of housemates, current employment status, years of schooling, current smoking status, current drinking status, type of medical insurance held, and MMSE-K score (measuring depression) or GDS-15 score (assessing cognitive impairment). We next used multivariate multinomial logistic regression to identify factors associated with four levels of morbidity: (a) no cognitive impairment and no depression; (b) depression only; (c) cognitive impairment only; and, (d) both cognitive impairment and depression. We adjusted for all covariates. All statistical analyses were performed using SAS software n  =  1,743), and 34.4% had never been schooled . Approximately 17% exhibited cognitive impairment (MMSE-K ≤24), and 26.0% evidenced depression (GDS-15 ≥8). Overall, 63.7%  showed neither cognitive impairment nor depression, 18.9% (n  =  574) showed only depression, 10.3% (n  =  314) presented only cognitive impairment, and 7.1% (n  =  216) exhibited both cognitive impairment and depression. MMSE-K and GDS-15 scores were correlated, with a correlation coefficient of –0.25 and a P-value <0.01, suggesting a positive association between better cognitive function and fewer depressive symptoms.The basic characteristics of the 3,041 participants who completed both the MMSE-K and GDS-15 and the mean scores on these two scales are presented in Factors significantly associated with depression were having no spouse and using the Medical Aid Program. Employment, more years of schooling, and higher MMSE-K score were associated with a decreased rate of depression after adjusted all the variables included in the univariate analysis .P-trend < 0.01), and receipt of Medical Aid Program benefits was associated with a greater likelihood of comorbidity . Females tended to experience cognitive impairment (only) more than males. Marital and employment status, and type of medical insurance held, were factors associated with the presence of depression (only). Year of schooling was the factor associated with the presence of only cognitive impairment or only depression.Multivariate multinomial logistic regression analyses showed significant associations of marital status, employment state, years of schooling, type of the medical insurance with comorbidity of cognitive impairment and depression . The oddWe investigated the prevalence of cognitive impairment, depression, and their comorbidity and factors associated with them among participants aged in their early 60s in a rural area of Korea. This may be the first study focusing on mental health problems and the comorbidity of these two conditions in subjects aged in their early 60s in Korea. The overall prevalence of cognitive impairment (MMSE-K ≤24) was 17.4%, that of depression (GDS-15 ≥8) was 26.0%, and that of comorbidity was 7.1%. Significant associations of gender, employment state, years of schooling, and GDS-15 score with cognitive impairment were observed. Marital status, employment state, years of schooling, type of medical insurance, and MMSE-K score were related to depression. The factors related to comorbidity were gender, marital status, employment status, years of schooling, and type of medical insurance.Results from a study that employed only the MMSE-K to estimate the prevalence of cognitive impairment among people ≥65 years of age showed a prevalence (17.0%) Education is strongly related to the risk of developing dementia A meta-analysis suggested that bereavement, sleep disturbances, disabilities, history of depression, and female gender were risk factors for depression among elderly individuals We found an independent association between cognitive impairment and depression after adjusting for sociodemographic factors. Many studies have shown a consistent association between the two This study has some limitations. We used a cross-sectional design, which is inappropriate for drawing causal inferences, so the results should be interpreted with caution. Second, generalization of the results should be made carefully, as the representativeness of the participants was limited, although most of the results were consistent with previous studies. Although the tools we used to measure cognitive impairment and depression have been validated in the Korean population, they are screening tools, and a measurement bias due to actual disease status may have occurred. Other mental health problems, for example anosognosia or anxiety which we did not measure might affect the score. Also, we measured only a limited number of variables and it is possible that an unmeasured trait was associated with cognitive impairment or depression. Finally, a nonresponse bias may have occurred. We did not examine the features of those who refused to participate and, thus, cannot estimate the extent of such bias. We suggest that any such effect may have been minimal, considering the high response rate.Despite these limitations, this study has several strengths. We investigated the factors associated with the comorbidity of cognitive impairment and depression, which have been rarely studied despite their clinical importance. Additionally, the study population consisted of subjects in their early 60s whose mental health has been rarely investigated even though they are entering an important “presenile” stage.We investigated correlated factors for cognitive impairment, depression, and comorbidity of the two conditions, and we found that the associated factors were similar among the three conditions through an exploratory way. Among the correlated factors, employment status and years of schooling were particularly strongly associated with all three conditions. The shared correlated factors or interactions between coexisting factors might lead to increased risk of both cognitive impairment and depressive symptoms. Considering the greater decline and increased risk for adverse outcomes among those with comorbid depression and cognitive impairment, it could be suggested that patients with either of these mental conditions should be evaluated for other mental conditions.


To the Editor: In 2004, the Cayenne General Hospital and public health centers recorded 348 new cases of cutaneous leishmaniasis (CL) in French Guiana , the incidence of CL in 2004 was 0.2%–0.4% and has been relatively stable since 1979  and 5.8S-13333-R (5´-CGACACTGAGAATATGGCATG-3´)  and with 239 inhabitants , Saint Elie is situated on a gold seam; miners illegally create trails from the village to deposits in a 10-km circumference in the dense forest around the village. Compared to other French Guianan villages, such as Saül and Régina, which are similarly isolated in the rainforest and have 160 and 765 inhabitants , respectively, and Iracoubo, the village closest to Saint Elie with 1,430 inhabitants , substantially more new CL cases have been observed in Saint Elie since 2003. Since 2000, medical rounds have been undertaken every 15 days in the villages of Saint Elie and Saül, whereas people from Régina and Iracoubo have doctors at their disposal every day.L. guyanensis . However, 860 new medical files have been registered in the Saint Elie Health Centre since 2000. This finding could be explained by the high number of illegal workers in this area. Patient interviews showed that most of these workers (≈90%) originated from the poorest northern Brazilian states . Thus, the incidence rate of 25.9%, calculated on the basis of 239 inhabitants, was likely overestimated. Taking into account a substantial turnover in migrant populations, the denominator could be 500–1,000 inhabitants, and the incidence rate would be 6.2%–12.4%. All patients worked in the small-scale gold mines surrounding Saint Elie, and CL cases were recorded without seasonal fluctuations. Imported cases are possible, but reports are likely to be anecdotal because clinical observations, estimated dates of infection, and duration of patient stay in Saint Elie were congruent and because all genotyped strains were Guianan –Several infection risk factors exist simultaneously in this situation. In a CL-endemic area, immigrant populations, who are mostly nonimmune, exert pressure on the environment (deforestation) that directly increases their risk for exposure to infected vectors, in the absence of prophylactic measures. The initial short-term effect of deforestation is the mobilization of aggressive adult sandflies, which have been disturbed while resting. However, the ability of zoophilic vectors to adapt to peridomestic environments has also already greatly influenced the distribution of leishmaniases in South America (Considering the uncertainty of the population estimate, turnover, and immunity status, we assume that incidence rates should be considered cautiously. Nevertheless, we found that gold mining in forested areas constitutes a risk factor for CL, at least in French Guiana and probably in all Amazonian rainforests. This risk could be a public health concern. Larger studies in other gold-mining areas are required to quantify the incidence of CL among workers to effectively focus prophylactic and preventive campaigns.


Herein we are the first to report that single-walled carbon nanotubes (SWCNTs) exhibit dual-phase regulation to Arabidopsis mesophyll cells exposed to different concentration of SWCNTs. The mesophyll protoplasts were prepared by enzyme digestion, and incubated with 15, 25, 50, 100 μg/ml SWCNTs for 48 h, and then were observed by optical microscopy and transmission electron microscopy, the reactive oxygen species (ROS) generation was measured. Partial protoplasts were stained with propidium iodide and 4'-6- diamidino-2-phenylindole, partial protoplasts were incubated with fluorescein isothiocyanate-labeled SWCNTs, and observed by fluorescence microscopy. Results showed that SWCNTs could traverse both the plant cell wall and cell membrane, with less than or equal to 50 μg/ml in the culture medium, SWCNTs stimulated plant cells to grow out trichome clusters on their surface, with more than 50 μg/ml SWCNTs in the culture medium, SWCNTs exhibited obvious toxic effects to the protoplasts such as increasing generation of ROS, inducing changes of protoplast morphology, changing green leaves into yellow, and inducing protoplast cells' necrosis and apoptosis. In conclusion, single walled carbon nanotubes can get through Arabidopsis mesophyll cell wall and membrane, and exhibit dose-dependent dual-phase regulation to Arabidopsis mesophyll protoplasts such as low dose stimulating cell growth, and high dose inducing cells' ROS generation, necrosis or apoptosis. Carbon nanotubes, as a class of stiff, stable and hollow nanomaterials with unique physical and chemical properties, have been being actively explored potential in applications such as biomedical engineering, bioelectronics, etc. -5. HowevArabidopsis, as an important model in plant biology and genetics, has been broadly investigated -20. ManyIn this study, we selected Arabidopsis thaliana as research target, and investigated the effects of highly purified SWCNTs on Arabidopsis mesophyll cells with the aim of observing active reaction and possible mechanism of plant cells exposed to different dose of SWCNTs.SWCNTs were purchased from Carbon Nanotechnologie, Inc. (CAS no.308068-56-6), their purity was 99.8%. Arabidopsis thaliana was provided by prof. Dabing Zhang in School of Life Science and Biotechnology of Shanghai Jiao Tong University. Mesophyll cells were freshly isolated from the leaves of wild-type Col-0 (top) growing on the soil. Other reagents such as fluorescein isothiocyanate (FITC) were purchased from Sigma–Aldrich, USA.SWCNTs were characterized by Atom Force Microscopy , dynamic2, 25 μl β-mercaptoethanol and 100 μl 10% bovine serum albumin (BSA), resultant final enzyme solution was filtered through a 0.45 μm syringe filter device into the Petri dish. Vacuum infiltrated leaf strips for 30 min in the dark using a desiccator, then continued the digestion for 3 h at room temperature under the condition of dark and no-shaking. Then checked the release of protoplasts in the solution under the microscope (Nikon TS100), and diluted the enzyme/protoplast solution with an equal volume of W5 solution composed of 2 mM MES (pH 5.7), 154 mM NaCl, 125 mM CaCl2 and 5 mM KCl. Then, washed a 75 μm nylon mesh with W5 solution, and filtered the enzyme solution including the protoplasts, and then centrifuged the filtered products at 600 rpm for 2 min, then removed the supernatant as much as possible, the final yield was the protoplasts. Then, the 6-well microplate was firstly washed by 5%(vol/vol) sterile BSA, and was added into 2 aliquots (0.5 ml each) of prepared Arabidopsis mesophyll protoplasts, then, the protoplasts was gently suspended with 1 ml washing and incubation (WI) solution , and was incubated at 22°C.The protoplasts were prepared by enzyme digestion method ,24. The The prepared protoplasts were cultured in 6-well microplate with WI solution. Then 15, 25, 50, 100 μg/ml SWCNTs solution were added into one well, and a control well without SWCNTs was set up. Meanwhile, the protoplasts were observed by microscope (Nikon TS100), one time per 8 h, until 48 h. FITC-labeled SWCNTs was prepared according to our previous reports , and incArabidopsis was cultured for 24 days, then the sterilized tweezers were used to slit wild-type lower epidermis of Arabidopsis leaves, then 50 μg/ml SWCNTs were dropped on the surface of mesophyll cells, kept for 2 h, and then slowly washed with sterilized water for three times, partial collected cells were embedded and made into transmission electron microscope (TEM) specimens, and then observed via a JEM-2100 electron microscope.The protoplasts were incubated with 50 μg/ml SWCNTs for 40 h, then, the protoplasts were stained with 50 μg/ml propidium iodide (PI) for 15 min and counter-stained with 3 μg/ml DAPI(4'-6-diamidino-2-phenylindole) for 5 min in the dark, finally those samples were observed by fluorescence microscope (Olympus IX71), and analyzed by flow cytometer (FCM).2 incubator, 10 μl of test solution was added to the protoplasts. Hydrogen peroxide (H2O2) was used as a positive control stimulus. Following exposure for 60 min, the protoplasts were washed by DPBS once and harvested with trypsin–EDTA. Finally, the protoplasts were suspended with 0.3 ml of 10% FBS in DPBS and passed through nylon mesh. The protoplasts were subjected to flow cytometry  until 20,000 events were recorded.The ROS assay was finished according to the manufacturer's manual. Briefly, the prepared protoplasts were incubated at 37°C for 24 h. Then, the culture medium was aspirated and the protoplasts were washed with Dulbecco PBS(DPBS) followed by the addition of 1 ml of fresh culture medium containing 10 μM carboxy-DCFDA  dissolved in DMSO. After the protoplasts were incubated for 15 min in a COt-test and considered significance at P < 0.05 level. All figures shown in this article were obtained from three independent experiments with similar results.All data are presented in this paper as means result ± SD. Statistical differences were evaluated using the As shown in Figure Arabidopsis mesophyll cells. It is the first to report that SWCNTs was confirmed to get through the Arabidopsis mesophyll cell wall, and enter into the inner organelles of the mesophyll cell. We also put the Arabidopsis mesophyll cells into different temperature solution such as 4, 25 and 40°C, and observed the fluorescent signal intensity, we did not observe the obvious changes of fluorescent intensity (data not shown), which highly suggest that SWCNTs likely get through plant cell wall and membrane by non-energy dependent endocytosis manner.As shown in Figure As shown in Figure We also observed the morphological changes of chloroplasts in protoplasts incubated with SWCNTs for 48 h. As shown in Figure P < 0.05). Therefore, we consider that low dose of SWCNTs can speed up the trichome development.However, surprisingly, we observed that, as shown in Figure P < 0.05. In control group, protoplasts often were live in WI solution for 4 days, our results showed that 50 μg/ml SWCNTs in a WI solution could speed up the death of protoplasts in WI solution, inducing green leaves into yellow leaves similar phenomena was also observed for those protoplasts treated with 100 μg/ml SWCNTs in a WI solution.The effects of SWCNTs on the viability of protoplasts incubated with 50 μg/ml SWCNTs were investigated. When the protoplasts were treated with 50 μg/ml SWCNTs for 40 h, we used propidium iodide (PI) and 4'-6-diamidino-2-phenylindole (DAPI) to stain the protoplasts, as shown in Figure We also used flow cytometry (FCM) to analyze these cells treated with 50 μg/ml SWCNTs, results showed that 70% or so cells exhibited apoptosis properties (data not shown). Therefore, more than 50 μg/ml SWCNTs could inhibit the growth of protoplasts by inducing apoptosis means, similar to our previous reports ,11.However, after the protoplasts treated with 25 or 15 μg/ml SWCNTs for 24 h, these protoplasts grew very well, and which fully showed that low dose of SWCNTs can improve the survivorship and development of protoplasts.Arabidopsis mesophyll cells by using DCF fluorescence as a reporter of intracellular oxidant production. As shown in Figure We investigated if SWCNTs causes ROS formation in the Up to date, the influence of nanomaterials on natural environment has become a hotspot. Carbon nanotubes, as one kind of promising nanomaterials, has been actively investigated potential application in biomedical engineering. However, so far the detailed mechanism of interaction between carbon nanotubes and the plant cells is still not well clarified.Arabidopsis mesophyll cell walls, and enter into intact Arabidopsis mesophyll cells, and then enter into the organelles such as chloroplast, vacuole, mitochondria, and nucleus, thus, SWCNTs may be a good molecular transporter in the plant world. At low dose of SWCNTs(less than 50 μg/ml) in culture media, SWCNTs can improve survivorship and development of plant cells, at high dose of SWCNTs in culture media (more than 50 μg/ml), SWCNTs exhibit obvious toxicity to Arabidopsis mesophyll protoplasts. The protoplasts gradually aggregated around SWCNTs, more and more wrinkles happened, as the incubation time of SWCNTs in WI solution with Arabidopsis mesophyll protoplasts increases, finally exhibited necrosis or apoptosis at high dose of SWCNTs. Our result also showed that SWCNTs can cause generation of a lot of intracellular reactive oxygen species (ROS) in plant cells incubated with different concentration of SWCNTs, which highly suggest that oxidative stress may be one of mechanism of active reaction of plant cells exposed to SWCNTs. Therefore, our results fully demonstrate that SWCNTs exhibit dual-phase regulation to plant cells in natural environment.In this study, we found that SWCNTs can get through the Arabidopsis mesophyll cells, SWCNTs enter into plant cells via non-energy dependent endocytosis pathway, which may be one kind of nanoscale capillary function, the van der Waals and hydrophobic forces are likely to be very important for the cellular uptake process of SWCNTs, similar to our previous report that DNA molecules entering into carbon nanotubes [With the regard to the uptake mechanism of SWCNTs by plant cells, so far it is not clarified well. It is well known that uptake of carbon nanotubes into mammalian cells is often by the endocytosis and insertion/diffusion . It has anotubes , furtherE. coli underwent severe membrane disruption and subsequent loss of viability due to SWCNTs [Regarding the toxicological mechanisms of carbon nanotubes, current reports mainly include three aspects such as oxidative stress, metal toxicity and physical piercing -27. For o SWCNTs , metal to SWCNTs -25. For o SWCNTs  reportedo SWCNTs ,30. For Arabidopsis mesophyll cells as follows: the SWCNTs in water solution can attach to the surface of plant cells, and penetrate cell walls into plant organelles by non-energy dependent endocytosis pathway, mainly locate in the vacuole, chloroplast, mitochondria, and nucleus, SWCNTs in the mitochondria may disturb the energy-metabolism course of plant cells, SWCNTs in chloroplast may disturb the photosynthesis course, SWCNTs in nucleus may damage the function of nucleus, at the same time, plant cells appear active reactions such as the shrink of plant cells, with the aim of fighting against the foreign invaders, when the balance between survivals and death was damaged, finally result in the apoptosis of plant cells. However, as we observed, low dose of SWCNTs improve the development of trichome clusters [In our study, in order to distinguish apoptosis of plant cells from death of plant cells, we used FCM to analyze the plant cell cycles, results showed that apoptosis cells reach 70% of total cells after incubation of plant cells with 50 μg/ml SWCNTs for 48 h. Programmed cell death (PCD) is an integral part of plant development and defense. Essential for normal functioning of plants, PCD may be found throughout the life cycle, from the fertilization of the ovule, to the formation of the xylem, to the death of the whole plant. Thus far, the fate of chloroplasts has been studied mainly during the developmental PCD of leaves that yellow at the end of the growing season. It is now widely accepted that the moment the cell dies during PCD is the time of vacuolar collapse, i.e., permabilization or rupture of the tonoplast. Organelles were degraded only after the rupture of the tonoplast, which releases hydrolases from the vacuole. The ER and Golgi bodies disappear, followed by the chloroplasts and mitochondria. The chloroplast matrix is degraded first, then the internal membrane structure . Therefoclusters ,34 and gclusters ,36, whicclusters , until rIn conclusion, our study provides the direct proofs that SWCNTs traverse across both the plant cell wall and cell membrane, high dose of SWCNTs exhibit toxic effects on the protoplasts, inducing changes of protoplasts morphology and protoplasts apoptosis, causing the production of intracellular ROS in plant cells, low dose of SWCNTs improve the survivorship and development of plant cells. Although present mechanism is not clarified well, this phenomenon should be the first report, which owns great potential in applications such as use of low dose of SWCNTs as the accelerated reagents for plant cells' growth and development, use of high dose of SWCNTs as toxic reagents to damage bad plant cells. Our studies lay foundation for further investigation mechanism of interaction between SWCNTs and plant cells in nature environment.


AbstractPorcellio siculoccidentalis Viglianisi, Lombardo & Caruso, 1992. Two species are new to Sicily: Armadilloniscus candidus Budde-Lund, 1885 and Armadilloniscus ellipticus . This is high species richness for a single reserve in Sicily. The extended sampling period also allowed us to study species phenology. Most of the species exhibited higher activity in spring than in autumn while some species also exhibited lower activity in the summer. The species richness revealed that the study area is in an acceptable conservation status; Shannon and Pielou indices also confirmed a more or less even distribution of individuals belonging to different species.Ecosystems comprising coastal lakes and ponds are important areas for preserving biodiversity. The natural reserve “Saline di Trapani e Paceco” is an interesting natural area in Sicily, formed by the remaining strips of land among salt pans near the coastline. From January 2008 to January 2010, pitfall trapping was conducted in five sampling sites inside the study area. The community of terrestrial isopods was assessed using the main diversity indices. Twenty-four species were collected, only one of them endemic to western Sicily:  Protected areas have restrictions on human activities aimed at preserving biotic and abiotic components of the landscape. Among the natural protected areas, coastal wetlands are particularly important ecosystems for preserving biodiversity . The natOniscidea in the natural reserve “Saline di Trapani e Paceco”. The specific aims were to study the phenology and frequency of the collected species, and to compare species composition and abundance in sites with similar anthropogenic disturbances to determine if there are differences among them. Oniscidean isopods play an important role in terrestrial ecosystems  is located in western Sicily, just south of the town of Trapani . The resPageBreakdata for the soil fauna  consisted of a small island connected to the land by the embankment of the Morana salt pan. Seven traps were recovered in S1 along a transect orthogonal to the coastline. Sampling site S2  consisted of strips of land comprising the embankments of the Anselmo salt pan, which consists of an uncultivated area. Six traps were recovered in S2 along a transect parallel to the salt pans. Sampling site S3  was located along the coast in an uncultivated area along the sea. Five traps were recovered in S3 along a transect parallel to the coastline. Sampling site S4  consisted of a large uncultivated area bordered by a pond on one side and the Baiata canal on the other side. Six traps were recovered in S4 along a transect orthogonal to a pond that borders the area. Sampling site S5  consisted of a narrow strip of land that separates the salt pans from the sea, a small island connected to the land by an artificial isthmus, which was made to create the embankments of the salt pans. Five traps were recovered in site S5 along a transect traced between the coastline and salt pans. All of the sites are level and characterized by homogeneous vegetation. Visitors to the reserve, salt pan activity, and grazing are disturbance factors for the sampling sites.Sampling site S1 , followed by autumn (176 mm); the rainiest month is December (75.1 mm). The average annual temperature is 18°C, with a maximum temperature of 41.8°C and minimum of 0.1°C.max / N, where Nmax is the number of individuals of the most abundant species), Shannon- Wiener diversity index (H’), and the Pielou evenness index (J’) , Berger-Parker dominance index (B = Ndex (J’) . SimilarArmadillidiidae were the most common , but Philosciidae , Porcellionidae , Armadillidae , and Halophilosciidae  were also well represented. The less represented families were Detonidae , Tylidae , and Ligiidae  , which were new to the fauna of Sicily, all species collected were already known from the area.A total of 24,109 isopod specimens were trapped, representing 24 species and 8 families . Species, 0.01%) . Among tPorcellionides pruinosus  and Porcellio laevis Latreille, 1804; Mediterranean-Atlantic: Tylos ponticus Grebnicki, 1874, Ligia italica Fabricius, 1798, Armadilloniscus ellipticus, Halophiloscia couchii , Armadillidium album Dollfus, 1887, Armadillidium granulatum Brandt, 1833, and Armadillo officinalis Dumeril, 1816; Holomediterranean: Chaetophiloscia elongata , Agabiformius lentusPageBreak , Agabiformius obtusus , and Leptotrichus panzerii ; North-Mediterranean: Stenophiloscia glarearum Verhoeff, 1908 and Halophiloscia hirsuta Verhoeff, 1928; West-Mediterranean-Atlantic: Armadilloniscus candidus, Porcellionides sexfasciatus , Lucasius pallidus , and Acaeroplastes melanurus ; South-MediterranPageBreakean: Mica tardus  and Porcellio albicornis ; Calabrian-Sicilian-South-Mediterranean: Armadillidium badium Budde-Lund, 1885and Armadillidium decorum Brandt, 1833; and endemic species: Porcellio siculoccidentalis.   . In S3, nt in S5 .Armadillidium granulatum.Shannon and Pielou indices had the lowest values in S5 and highest values in S3 . SamplinPageBreakPageBreakThe Jaccard index ranged from 0.43 to 0.72, with sites S3 and S5 being the most similar. The Sörensen index ranged from 0.03 to 0.52. The most similar pair of sites was S1 and S4, and the less similar was S4-S5 .Analysis of the temporal frequency in the overall study area showed that 11 species were constant (F ≥ 50%), only one species was accessory (25 ≤ F < 50%), 6 were accidental (10 ≤ F < 25%), and 6 were sporadic (F < 10%). The frequency category for each species did not change in the different sites in regards to the accidental and sporadic species, whereas constant species were not the same among sites .Chaetophiloscia elongata, Porcellio laevis Latreille, 1804, and Armadillidium granulatum. Porcellio laevis was constant at all sites  were constant species in S3, though they sometimes changed frequency category in the other sites; Chaetophiloscia elongata was accessory in S5, Armadillidium granulatum was accessory in S1 and accidental in S4, Leptotrichus panzerii was accidental in S4, Armadillidium badium was accidental in S2 and sporadic in S5, Armadillo officinalis was accidental in S2 and accessory in S5, Agabiformius lentus was accidental in S1 and S4 and accessory in S2 and S5, and Halophiloscia couchii was sporadic in S2 and S5. Two species, Porcellio siculoccidentalis and Armadillidium decorum were constant in only one sampling site, S1 and S4, respectively. Acaeroplastes melanurus was not constant in any site. The number of sporadic species varied from two in S2 to nine in S5 , which were present more in S1 (38.7%) and S3 (61%) , which were found mostly in S3 (48%). The species showed an activity period from February to June in both years. After the summer in which there was no activity, the curve showed a rise with a peak in late autumn , which were distributed equally in the five sampling sites. Generally, this species exhibited weak activity that intensified slightly in May and December of the first year and June of the second year  and found only in S1 . The activity of this species started in March, reached a peak in June, and decreased during the summer months. In winter, a second small peak was observed . The phenological curve showed a bimodal trend in both years, with a peak of activity in April and January of the first year and November of the second year  were collected in S5 (85%). This species showed early activity in March, a peak in late spring, and reduced activity in August . Leptotrichus panzerii was represented by 1440 individuals, which were collected mostly in S2 (50.5%). Porcellio laevis and Armadillo officinalis exhibited activity throughout the sampling period with two peaks, in the spring and summer . Armadillo officinalis was represented by 1291 individuals, which were collected mostly in S4 (69.3%)  in the five sampling sites and to study the activity trend during the sampling period. S3 (61%) . We obseS3 (61%) . Chaetope autumn . Agabifoond year . Porcelln autumn . Porcellly in S1 . This spobserved . Armadilond year . Armadiln August . AcaeropDecember . Acaeropd summer . Porcell (69.3%) .PageBreakPageBreakcies come from all kinds of biotope . Comparing these data with other research concerning the diversity of terrestrial isopods in the coastal wetland of Vendicari  . The area of Vendicari seems to be in a better condition than the “Saline di Trapani e Paceco” due to the presence of new species belonging to the genera Bathytropa, Spelaeoniscus, and Haplophthalmus, the former two of which are endemic to the area and belong to genera known to be highly sensitive even to low levels of environmental degradation. Indeed, species belonging to Bathytropa and Spelaeoniscus live almost exclusively in undisturbed habitats . The 24 species collected were found in very similar habitats, whereas the Sicilian sperovince) , the numhabitats .Ligia italica, Chaetophiloscia elongata, Porcellionides pruinosus, Porcellionides sexfasciatus, Leptotrichus panzerii, Porcellio laevis, Armadillidium granulatum, and Armadillo officinalis) in common with the present study area. In the Berkoukech area (north-west of Tunisia), 12 species of terrestrial isopods were collected  are also present in our study area. In the Moula-Bouterfess area, 11 species were collected (Chaetophiloscia elongata and Porcellionides sexfasciatus) in common with our study. Comparisons with these data, however, are spurious because of different sampling methods.The species richness in “Saline di Trapani e Paceco” is significantly higher than that of other Mediterranean wetland sites. In coastal wetlands in Tunisia, 14 species were collected , eight of which , coastal , sabulicolous (Agabiformius lentus and Leptotrichus panzerii), xerophilic ; pratinicolous , humicolous , anthropophilic (Porcellionides pruinosus and Porcellio laevis), and myrmecophilous species .Considering the ecological requirements of the 24 species, they can be grouped as littoral halophilic iPageBreakn North America  with millions of individuals in the spring of 1998.All sampling sites except S2 have a high and comparable number of species, but vary in composition. In sampling sites S1, S3, and S5 we found halophilic species whereas in S2 and S4 these species were absent, except for terature , such as America  and Armahe night . An enorArmadilloniscus candidus, Armadilloniscus ellipticus, Halophiloscia couchii, Halophiloscia hirsuta, and Stenophiloscia glarearum and the coastal species Armadillidium granulatum. Halophilic species determine the qualitative similarity among all sites. The less similar sites are S4 and S5 (9 species in common) because S4 lacks halophilic species and is richer in species that prefer wet and open areas, such as Lucasius pallidus and Mica tardus.Comparing the similarity values (Jaccard index) among the sampling sites, S3 and S5 were qualitatively more similar, having 13 species in common, including strictly halophilic species The quantitative Sörensen index showed generally low values. S1 and S4 were fairly similar, whereas S4 and S5 were less similar, as for Jaccard’s index.Armadillidium badium which lives in grasslands and prefers open areas  between the coastline and salt pans. A majority of the sporadic species are halophilic species typical of the habitats present in this site. Such low frequency values can be explained by the fact that almost all species, including Armadilloniscus candidus, Armadilloniscus ellipticus, Halophiloscia couchii, Halophiloscia hirsuta, Stenophiloscia glarearum, and Armadillidium album, live near the shoreline and rarely move away. The lack of Tylos ponticus is strange because migration from the sea to inland and vice versa occurs every night, up to 200 meters from the shoreline (Analysis of the temporal frequency of the species in each site showed constancy of species tied to specific habitats. For example, en areas , was conhoreline .Halophiloscia couchii, Chaetophiloscia elongata, Agabiformius lentus, Porcellio albicornis, Porcellio siculoccidentalis, Armadillidium badium, Armadillidium decorum, and Armadillidium granulatum, exhibit high activity in spring and decreased activity during the driest months. A second peak occurs in autumn, perhaps corresponding to the activity of the spring generation. This general trend varies for Acaeroplastes melanurus, Leptotrichus panzerii, Porcellio laevis, and Armadillo officinalis, which exhibit low activity in the summer.Most of the species, specifically Halophiloscia couchii is more active in April and October. Comparing the results obtained here with those that emerged from similar research carried out in the natural reserve of Vendicari (PageBreakpeaks in the spring and autumn. The activity periods of Chaetophiloscia elongata, Armadillidium badium, and Armadillidium granulatum do not coincide; in Vendicari Chaetophiloscia elongata is most abundant in the summer, whereas Armadillidium badium and Armadillidium granulatum peak in autumn.The different types of sampling methods used in other studies of similar habitats , does noendicari , we veriArmadillidium granulatum in S5, with a population explosion that could be due among other factors to a drastic decrease in predators due to human activities.In the present study area, no species of special conservation concern has been found. Nevertheless, and despite the fact that the area is disturbed by human activity at the salt pans, it can be considered of a good environmental quality and of some conservation interest. This conclusion can be inferred by the relatively high number of isopod species and the generally even distribution among them. The only exceptional case was


Mammary myofibroblastoma (MFB) is a rare benign spindle neoplasm that affects both sexes with a male predominance. It can exhibit a wide range of histological patterns. We report a case of epithelioid/spindle MFB of the female breast with admixed, but distinct, foci of spindle cell lipoma. Whilst all the spindle cells within the tumour expressed CD34, AR, ER, BCL2, and CD10, only those within the myofibroblastoma expressed desmin and only those within the lipomatous areas expressed S100. This finding, to our knowledge, is a novel one that has not been reported before. Mammary myofibroblastoma (MFB) is a rare benign spindle neoplasm that affects both sexes with a male predominance. It can exhibit a wide range of histological patterns including 1) collagenized/fibrous, 2) cellular, (3) lipomatous, (4) infiltrative, (5) myxoid, (6) epithelioid, and (7) deciduoid-like variant [ collagen cellularThere is a case of myofibroblastoma of the male breast with pleomorphic lipoma-like areas . There hWe report a case of epithelioid/spindle MFB of the female breast with admixed, but distinct, foci of spindle cell lipoma. This finding, to our knowledge, is a novel one that has not been reported before.An elderly female patient was admitted to Charing Cross Hospital for breast screening. Mammography and ultrasound identified a small nodule in her left breast suggestive of a benign lesion, possibly a fibroadenoma. This was then sampled with an US guided core biopsy. The histology showed fibroadenomatoid change in one core. The other core demonstrated groups of ovoid/epithelioid and fascicles of bland spindle cells separated by bundles of hyalinised collagen. These lesional cells were positive for desmin and negative for AE1/3, S100, and SMA. There was no evidence of DCIS or malignancy. An excision biopsy was advised to enable further characterization of the lesion.The wide local excision specimen on slicing revealed a 12 mm well-defined firm grey nodule. Sections were stained for H&E and a number of antibodies including AE1/3, CK5, S100, SMA, Desmin, CD34, BCL2, ER, AR, and CD10.Microscopic examination of the H&E sections demonstrated a well circumscribed, nonencapsulated lesion composed of bland slender, spindle, and epithelioid cells with moderate amount of cytoplasm arranged haphazardly in fascicles and in clusters separated by thick hyalinised bundles of collagen. These features were considered to be consistent with a myofibroblastoma . OccasioImmunoperoxidase staining showed that the main tumour cells expressed desmin and lacked S100 expression Figures  and 4. IMyofibroblastoma of the breast is a rare lesion that can show a wide variety of different morphologic patterns some of which can be similar to other spindle-cell benign tumours of the breast, like solitary fibrous tumour (SFT) and spindle cell lipoma (SCL). The recognition of these patterns is vital to avoid erroneous confusion with malignant lesions , 4, 5. WHerein, we report a rare case of epithelioid/spindle MFB of the female breast with admixed, but distinct, foci of spindle cell lipoma. This finding, to the best of our knowledge, has not been reported before. Our case reinforces the close relationship between spindle cell lipoma and myofibroblastoma and supports the concept suggested by Magro et al.,  which is


A boy aged 4 months 7 days was admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of icddr,b, Dhaka, Bangladesh, with the problems of acute watery diarrhoea with some dehydration, pneumonia, lethargy, and hypernatraemia (serum sodium of 201 mmol/L). Correction for hypernatraemia was tried by using only oral rehydration salt (ORS) solution. Seizures occurred during correction of the hypernatraemia. These were difficult to control and required three doses of injection lorazepam, a loading dose of injection phenobarbitone, followed by injection phenytoin and finally two doses of injection mannitol . The correction was continued with ORS, and all the anticonvulsants were successfully weaned without any further seizures, and the patient recovered without any overt neurological sequelae. We present a case report of extreme hypernatraemia, which was successfully managed using only ORS. Hypernatraemia is a serious ramification of diarrhoea often associated with death . Death mThe Dhaka Hospital of icddr,b admits a large number of diarrhoeal patients, and a number of them also present with hypernatraemic dehydration. Most of the patients receive only ORS for the correction of hypernatraemic dehydration, irrespective of the level of serum sodium. A report of a patient whose serum sodium was 201 mmol/L and received only ORS for correction, is presented here.A boy aged 4 months 7 days from a middle-class family  living in Dhaka district was brought to the Dhaka Hospital of icddr,b on 9 January 2011 and admitted to the Short Stay Unit on the same day. Immediately after admission, he was shifted to the hospital's ICU for his respiratory distress and irritability. He had a history of watery diarrhoea for 3 days, associated with vomiting for the same duration, fever and respiratory distress for the last 12 hours. His stool frequency was 12 times/day, vomiting 2 times/day, and fever was high and continued but not associated with chills and rigours, and respiratory distress was not associated with cough. The child had passed urine half-an-hour before admission in the ICU. He received 6 packets (3 litre) of inappropriately-prepared (concentrated) ORS at home but no drugs. History of his past illness was unremarkable. He did not have a history of contact with any persons known or suspected to have tuberculosis, and his family members were in good health. He was the second and the last issue of his non-consanguineous parents and was delivered normally at home at full term. His weight and height at birth could not be obtained. He was breastfed at birth, and it continued up to 2 months. Since then, he was given mixed-milk (formula milk and breastmilk). His developmental milestones were age-appropriate, and his vaccinations were up-to-date according to the local EPI (Expanded Programme on Immunization) schedule. Both the parents were literate (education of the father and the mother was up to college and high school level respectively); the father was a garments worker, and the mother was a housewife. They were living in a tinshed house, used to drink tubewell water but their sanitation was poor.On admission, the infant was initially irritable and excessively thirsty but he became very lethargic soon after admission. His pulse rate was 146 per minute with normal volume, blood pressure was 85/60 mmHg, capillary refill time was <2 sec, rectal temperature was 39.5 °C, and respiration rate was 80 per minute. He weighed 6.4 kg and had a length of 60 cm; his anthropometric measurements showed a z-score of <-2 [>-3 of the median of WHO growth charts] for all of the three indices—weight-for-age, weight-for-length, and length-for-age. He had some dehydration but did not have pallor, cyanosis, jaundice, oedema, or clubbing.2) was 96% in room-air (WHO defines SPO2 of <90% at sea-level as hypoxaemia).There was no increased work of breathing . His trachea was centrally placed, and the respiration sounds were vesicular with no adventitious sounds . Other systemic examinations of the infant were not remarkable. His blood glucose, measured at bedside, was 7.30 mmol/L, and his arterial oxygen saturation  acute watery diarrhoea with some dehydration, (b) hypernatraemia , (c) pneumonia (according to WHO definition), and (d) lethargy .The laboratory work included: blood for total and differential white blood cell (WBC) count; blood culture and sensitivity; serum electrolytes, including serum total calcium, total magnesium, serum creatinine; rectal swab culture for isolation and identification of enteric pathogens; urine for routine and microscopic examinations (RME); and urine for culture and sensitivity (as a part of routine investigations in a febrile infant); and a chest x-ray.We started management of dehydration with ORS following WHO guideline . Parente3, with 55.1% neutrophils, 0.0% bands, 33.5% lymphocytes, 11.2% monocytes, 0.1% eosinophil, and 0.1% basophil. Serum sodium was 201.0 mmol/L, chloride 165.3 mmol/L, potassium 3.6 mmol/L, TCO2 20.3 mmol/L, total calcium 1.94 mmol/L, total magnesium 1.31 mmol/L, and serum creatinine 66.6 micromol/L. The chest x-ray and urine RME revealed normal findings.His total WBC was 9,600/mmAfter receiving the electrolyte report (around 4 hours after initiation of hydration), we re-evaluated the dehydration status and found no signs of dehydration. Then we decided to manage the correction of hypernatraemic dehydration, using ORS only. The volume required was calculated following a formula [10÷(molecular concentration of sodium in a given solution–measured serum sodium)/(0.6×weight in kg+1)=litre/24 hours] .Correction of hypernatraemia was started with a calculated rate of ORS of 15 mL per hour through nasogastric tube, and the correction of hypocalcaemia was tried with 10% calcium gluconate injection (0.5 mL/kg), and oral supplementation with calcium carbonate tablet was continued during hospitalization. Ten hours after initiating the treatment of hypernatraemia (14 hours after admission), the patient developed a generalized tonic clonic seizure. The seizure was difficult to control and required a total of three doses (0.1 mg/kg/dose) of injection lorazepam (10 minutes apart), followed by a loading dose of injection phenobarbitone (20 mg/kg) and injection phenytoin (20 mg/kg). Simultaneously, a maintainance dose of phenobarbitone (5 mg/kg/day in two divided doses) and phenytoin (2.5 mg/kg/dose 12 hourly) were continued to prevent further convulsions. After cessation of the convulsion, we re-examined the child and did not find any signs of meningism except extreme lethargy. We differentially thought that convulsion was either due to hypernatraemia itself or due to cerebral oedema from a probable rapid fall in sodium. The serum sodium level after 24 hours was 185 mmol/L, and the fall was >0.5 mmol/L/hr. We examined the fundi and did not find any evidence of cerebral haemorrhage or cerebral oedema. However, there was another episode of generalized tonic clonic convulsion which was not controlled by an additional dose of injection lorazepam (0.1 mg/kg/dose), and an empirical dose of 20% mannitol injection [0.5 g (2.5 mL)/kg/dose] was given due to the likelihood of cerebral oedema; the convulsion was controlled after infusion of mannitol. We gave another dose [0.5 g (2.5 mL)/kg/dose] of mannitol 6 hours after the initial dose. We re-examined the fundi and still did not find any evidence of cerebral oedema and, therefore, stopped mannitol. Then approximately every 24 hours, the serum sodium was checked , and the volume of ORS needed for the correction of hypernatraemic dehydration was re-calculated each day. On average, the fall was <0.5 mmol/L/hr for the next 4 days during the correction. In the mean time, by day 3, diarrhoea was controlled, and clinical signs of pneumonia disappeared but the patient was still lethargic. The lethargy might have been due to the use of two anticonvulsants and as there were no further episodes of convulsion, the anticonvulsants were weaned after a convulsion-free period of 48 hours; all the anticonvulsants were gradually weaned successfully by day 7. On day 7, the patient was active and alert, took food orally and was gradually becoming afebrile. There were no CNS abnormalities. In the mean time, no organism was isolated from blood, rectal swab or urine culture, and we stopped antibiotics and planned to discharge the patient.Before discharge , a computed tomography scan of brain was performed, which revealed mild ischaemic changes in both the temporal lobes . After rWe have a few distinct observations from this case study. This febrile young infant with acute watery diarrhoea had the highest serum sodium reported in the literature that was successfully managed using only ORS, though we had difficulty in controlling seizure during the initial correction.The presence of 201 mmol/L of serum sodium was probably due to a combination of several factors, including early infancy, taking concentrated ORS after each purging, high fever, pneumonia with fast breathing, and probably having rotavirus diarrhoea—the most common pathogen during the winter season. Taking concentrated ORS gives rise to hyperosmolality of the extracellular fluid, causing hypernatraemia, simultaneously leading to the movement of water from the intracellular fluid (ICF) to the ECF, resulting in intracellular dehydration and excessive thirst ,15. In BOur observation of the successful use of ORS through a nasogastric tube for the slow correction of hypernatraemic dehydration in this infant might be the secret for the successful correction of extreme hypernatraemia. The formula that we have used for the correction of hypernatraemic dehydration has been well-tested in adults  but thisThe child might develop problems of speech perception, with difficulty in discriminating speech in advancing age but young children have an ability to let the remaining part of the brain take over the function of a damaged part . The chiThe use of only ORS for the correction of extreme hypernatraemia in a young infant has been found to be very successful. Thus, scrupulous adherence to the use of ORS in such a case may be the choice for the management of hypernatraemic dehydration. However, before making a final recommendation, a randomized clinical trial to evaluate the efficacy of ORS compared to intravenous solution is imperative.


A review of the related medical journals indicates that there is no definite evidence-based option for managing large proximal ureteral stones, although many procedures such as transureteral lithotripsy (TUL), shock wave lithotripsy (SWL), percutaneous nephrolithotripsy, laparoscopic ureterolithotomy, and open ureterolithotomy are currently used to treat this urological problem.In this study, we tried to determine the most appropriate treatment plan for proximal ureteral stones larger than 12 mm by comparing the two most commonly used procedures.Between February 2005 and April 2011, 62 patients including 40 males and 22 females  with proximal ureteral stones larger than 12 mm (12–26 mm) with a mean size of 17.64 mm were prospectively divided into two groups consisting of 32 patients who underwent TUL (group A) and 30 who underwent SWL (group B). In unsuccessful cases, repeat SWL or TUL was planned. Patients who could not tolerate the lithotomy position, younger than 18 years, had undergone coagulopathy, had concurrent renal and ureteral stones, were pregnant, or had sepsis were excluded from this study.Stone access was successful in 28 patients and the treatment was efficient in 18 patients (56.25%) in group A. For the patients with successful stone access but unsuccessful TUL, a DJ was inserted and a second ureteroscopic intervention was performed. The second intervention was successful in 7 patients (21.87). SWL was successful in 14 patients (46.66%) in the first attempt and in 7 additional patients in the second intervention (23.33%).In this study, we showed different success rates for SWL and TUL because of the larger size of the stones. We achieved a success rate of 56.25% in the first attempt in the TUL group, and the overall success rate (after the second TUL) was 78.12%. In comparison, the SWL group had a success rate of 46.66% in the first attempt, and the overall success rate (after the second SWL) was 69.96%. A review of the related medical journals indicates that there is no definite evidence-based option for managing large proximal ureteral stones. The goal of treating ureteral calculi is to achieve complete stone clearance with minimal patient morbidity. Shock wave lithotripsy (SWL) and ureteroscopy have become standards of care for ureteral calculi. However, the optimal choice of treatment depends on various factors, including stone size, composition and location, clinical factors, equipment availability, and surgeon capability . CurrentIn this study, we tried to determine the most appropriate treatment plan for proximal ureteral stones larger than 12 mm by comparing two most commonly used procedures.Between February 2005 and April 2011, 62 patients including 40 males and 22 females  with proximal ureteral stones larger than 12 mm (12-26 mm) and with a mean size of 17.64 mm were prospectively allocated randomly in 2 groups. Before the operation, ureterolithotomy was offered to the patients as the salvage procedure but never was needed in this study. The advantages, disadvantages, and possible side effects of each method were carefully explained to patients before obtaining informed consent. The success or failure of the procedure as well as the time needed for each procedure, cost, postoperative analgesic use, complications, stone clearance, and hospital stay were compared in the two groups.In group A, 32 patients underwent URS with a semi-rigid wolf 8–9. 8F ureteroscope, and TUL was performed in successfully accessible cases. In nonaccessible cases, a 4.8F double-J stent was inserted blindly next to the stone, after unwanted pushed-back stones, or for large displaced fragments. Accessibility was defined as being able to reach the stone through the ureteroscope, and a successful outcome was defined as the patient being stone-free on radiography and ultrasound one month after the treatment. The procedure was performed under spinal anesthesia in group one. The sources of energy in the TUL group were ultrasonic and pneumatic.In group two, 30 patients underwent SWL under intravenous sedation with pethidine as an outpatient procedure. The initial voltage of each shock wave was 13 kV, which was gradually increased to 18 kV. The maximum number of shock waves was limited to 4,500. In unsuccessful cases, repeat SWL or TUL was planned. Lack of success was defined as no change in the stone burden after the first postoperative X-ray and ultrasound one week after the operation, and a successful outcome was defined as a stone-free state one month after the procedure. Asymptomatic residual stones with a size of less than 5 mm were ignored. The lithotriptor used in the SWL group was the Dornier compact delta 2 lithotripter.The indication for treatment was proximal ureteral stones larger than 12 mm (12–26 mm). Patients who could not tolerate the lithotomy position, younger than 18 years, had undergone coagulopathy, had concurrent renal and ureteral stones, were pregnant, or had sepsis were excluded from this study.A preoperative conventional X-ray of the kidneys, ureter, and bladder (KUB) as well as ultrasound or excretory urography (IVP) were performed in all cases to determine the stone size and location and to estimate renal function and hydronephrosis. The postoperative image protocol included KUB and renal ultrasound to monitor the recovery of hydronephrosis and stone passage weekly. Treatment outcomes were determined based on evidence of being stone-free on KUB and ultrasound one month after the initial therapy.The stone-free rates of the two methods were compared using Fisher’s exact test. Stone size, operation time, and age of the participants in the two groups were compared by an independent sample t-test. In addition, the cost in the two groups was analyzed in terms of the cumulative fees of preoperative evaluation, operation, perioperative monitoring, postoperative care, office visits, ancillary procedures, and re-treatment procedures.Stone access was successful in 28 patients and treatment was efficient in 18 patients (56.25%) in group one. For the patients with successful stone access but unsuccessful TUL, a DJ was inserted and a second ureteroscopic intervention was performed. The second intervention was successful in 7 additional patients (21.87). Double-J stents were also used in some cases with successful results to facilitate the recovery period. These stents were inserted in 20 patients because of the large stone burden, which enabled stone passage and prevented immediate postoperative complications, particularly in case of unsuccessful stone access or escaped stones in group one. The initial stone-free rate of the TUL group was 56.25% (18 of 32), and the final stone-free rate was 78.12% (56.25 + 21.87).SWL was performed as a primary procedure in 30 patients. The initial stone-free rate for SWL was 46.66% (14 of 30), and in the second session it was successful in 7 more patients (23.33). Thus, the final stone-free rate in this group was 69.99%. The difference in the proportion of success between the two groups was significant . There wThe cost of SWL in Iranian hospitals, particularly in nongovernmental hospitals, is definitely greater than that of TUL, even in the case of an ancillary procedure like DJ stent insertion. No significant complication was encountered in this study , except for low-grade fever of a limited duration  and minor complications related to anesthesia . The mean number postoperative office visits was higher in the SWL group (4 visits versus 2.2).The likelihood of the passage of a ureteral stone depends on stone size, location, configuration, and presence or absence of co-morbidities. Most stones ≤4 mm may pass spontaneously. For larger stones, there is a progressive decrease in spontaneous stone passage. The management of large proximal ureteral stones remains challenging for urologists . These sOthers have demonstrated that URS with laser lithotripsy achieves excellent results for upper ureteral calculi greater than 1 cm . Thus, t