The safety of Zigbir®, a polyherbal formulation intended for use as food supplement, was evaluated in Sprague-Dawley rats treated orally at the dose of 2000 mg/kg in acute and at 250, 500, and 1000 mg/kg for 90 days in subchronic toxicity study. The median lethal dose of Zigbir® was found to be more than 2000 mg/kg, and fourteen-day repeated dose toxicity study revealed it to be safe up to 1000 mg/kg. The subchronic study did not show any mortality or treatment-related adverse clinical signs. The treated animals exhibited normal feed intake and comparable body weight gain except for a decrease in females of 500 and 1000 mg/kg groups. Ocular examination revealed no abnormalities. Further, Zigbir® administration in rats did not induce any major changes in urinalysis, hematological, and biochemical evaluations except for minor alterations in few parameters at different dose levels. Gross and histopathological findings did not show any lesions attributable to Zigbir® administration. The no observed effect level of Zigbir® was found to be 500 and 250 mg/kg in male and female Sprague-Dawley rats. Development and assessment of herbal formulations for various beneficial health and or functional effects in animal and human species are increasing in popularity. Despite well-established scientific studies on phytopreparations or herbal ingredients for pharmacological properties, the safety details of herbal substances reported in compliance to internationally accepted guidelines seem to be inadequate –3. In viAndrographis paniculata (A. paniculata), Boerhaavia diffusa (B. diffusa), Phyllanthus amarus (P. amarus), and Solanum nigrum (S. nigrum) that protect the liver from variety of toxins. This polyherbal preparation, recommended in poultry birds, tones up the liver and enhances hepatic functions, accelerates the regeneration process, and stimulates sluggish liver parenchyma. It also improves the secretion and flow of bile and helps in fat metabolism. The investigational substance of the present study, Zigbir®, is a polyherbal formulation consisting of four medicinal plants, namely, A. paniculata (Acanthaceae), also known as King of Bitters, is extensively used alone or in combination with other herbs in many hepatoprotective preparations in Indian system of medicine [A. paniculata and a diterpenoid lactone, has been shown to be chiefly responsible for the antihepatotoxic activity of the herb in different animal models. Andrographolide showed protective effect against carbon tetrachloride [A. paniculata extract treatment increased biliary flow and liver weight and reduced the duration of action of hexabarbital in laboratory rats [The hepatoprotective effects of herbal ingredients of Zigbir® have been well established in published literature. medicine –6. Androchloride , paracetchloride , ethanolchloride , and galchloride  induced ory rats . Adminisory rats .B. diffusa (Nyctaginaceae) on oral administration at 500 mg/kg to adult male Swiss mice and Charles Foster rats exhibited hepatoprotective properties, decreased barbiturate sleeping time, prothrombin time, and lowered plasma bilirubin levels. The extract was also reported to be safe even up to 2000 mg/kg in mice [B. diffusa against carbon tetrachloride-induced hepatic damage in isolated rat hepatocytes [An alcoholic extract of  in mice . Chakrabatocytes .P. amarus (Euphorbiaceae) at 200 mg/kg treated orally improved liver regeneration in male Wistar rats with alcohol induced liver damage [in vitro effect of P. amarus on hepatitis B virus and found that the alcoholic extracts of P. amarus were effective against HBV antigens, the butanol extract being the most potent [in vitro conditions, aqueous extract of S. nigrum (Solanaceae) suppressed aflatoxin production by Aspergillus flavus and thereby protected the liver. The hepatoprotective activity of S. nigrum could be due to the inhibition of oxidative degeneration of tissue DNA [r damage . Mehrotrt potent . The actssue DNA .Despite the availability of extensive pharmacological information for the aforementioned medicinal plants on the hepatic function, only few reports are existing that describe the safety evaluation of individual plant ingredients carried out in conformity to universally accept testing protocols. In addition to the beneficial effects observed, it is also imperative to generate comprehensive toxicological information of the test substance for ensuring safety upon use, especially for longer periods. In the present study, therefore, we conducted acute and subchronic oral toxicity studies on Zigbir® in rats, to establish the no observed effect level (NOEL) and to determine its safety to be used as a hepatoprotective agent.A. paniculata (27.7% w/w), P. amarus (27.7% w/w), S. nigrum (27.7% w/w), and B. diffusa (16.9% w/w). The plant materials used were analyzed for respective marker compounds by high performance liquid chromatography (HPLC) method and by liquid chromatography-mass spectrometry (LCMSMS) methods.Zigbir® is a combination of four medicinal herbs developed by M/s Natural Remedies, Bangalore, India. Zigbir® has 254 plate of 0.2 mm thickness as bands. The plate was developed in a mobile phase consisting of toluene : ethyl acetate : acetic acid (55 : 45 : 2). The dried plate was scanned at 254 and 366 nm. The plate was sprayed with anisaldehyde sulphuric acid reagent and dried in oven at 100°C. The fingerprint of the product sample was compared with reference standard.The crude powders obtained from the plant materials, after verifying the content of marker compounds, were mixed in appropriate proportions, grinded, and blended to prepare Zigbir®. The thin layer chromatography (TLC) profile of product was compared with the reference material using high performance thin layer chromatography (HPTLC) analysis. The product and respective reference standard weighing 5.0 g were weighed separately and extracted separately using reflux condenser on a water bath using 80 mL methanol for 30 min. The filtrate is decanted and the residue is again extracted with 80 mL methanol for 30 min and the process is repeated twice and then filtered after cooling. The filtrate was concentrated to 25 mL. Equal volumes (15 mcg) of sample and reference standard were spotted on Silica gel 60 Fad libitum.Sprague-Dawley rats (6–8 weeks) used in the present studies were bred and reared at Indian Institute of Toxicology, Pune, India. The animals were housed in polypropylene cages with stainless steel grill tops and bedding of clean paddy husk in a temperature-controlled animal room (20–24°C) with a relative humidity of 30–70%, 10–15 air changes per hour, and illumination cycle set to 12 h light and 12 h dark. Standard pelleted rodent feed  and filtered and UV exposed portable water (Aqua guard) were provided A preliminary sighting study, followed by main study, was conducted to assess the acute oral toxicity of Zigbir®, administered as a suspension in 0.5% aqueous carboxymethylcellulose (CMC) to five female rats (eight weeks old) at 2000 mg/kg body weight as a single oral dose in a sequential manner. The dose volume was kept as 20 mL/kg body weight. The rats were fasted 16 h before and 3 h after the administration of the test material and only water was provided during the period. All the animals were observed for mortality (twice daily) and clinical signs for first 10 min, 30 min, 1 h, 2 h, 4 h, and 6 h after dosing and thereafter once a day for continuous 14 days. The body weight of rats was recorded following the period of fasting on day 0, weekly thereafter and at termination of study on day 15 and weekly body weight gain was calculated. Necropsy was carried out on all rats that were sacrificed at the end of the experiment. This study was performed in compliance with the OECD guideline for testing of chemicals: Test guideline No. 420, Acute oral toxicity-fixed dose method and with Schedule Y, Drug and Cosmetics (Eighth amendment) Rules-1988, Ministry of Health & Family Welfare, Government of India , 18. A dose range finding study was conducted to evaluate the potential toxicity of repeated exposure of Zigbir® in Sprague-Dawley rats to select dose levels for a 90-day subchronic toxicity study. In this study, groups of 5 male and 5 female rats were administered freshly prepared doses of Zigbir® daily by oral gavage for a period of 14 days at 100, 250, 500, and 1000 mg/kg. A concurrent control group of rats received vehicle (0.5% CMC) alone. The rats were observed for mortality and clinical signs during the 14-day observation period. Body weight and feed intake of treated rats were recorded at initiation of the study and weekly thereafter. All the surviving rats were sacrificed on day 15 for gross pathological examination.A 90-day, subchronic oral toxicity study was conducted in accordance with the OECD guideline for testing of chemicals: Test guideline No. 408, repeated dose 90-day oral toxicity study in rodents , and in All animals were observed twice daily for mortality during the study period. Also, abnormal clinical signs or reactions to treatment , if any, were recorded. The body weight and feed consumption data were recorded on the day of commencement and at weekly intervals throughout the study period in all the groups and in recovery groups during the posttreatment period also.Eye examination of control and all the treated animals was conducted prior to initiation of the study and during weeks 13 and 17 (for recovery groups), using a hand slit lamp after induction of mydriasis with 0.5% tropicamide solution.During week 13, all animals were examined for sensory reactivity to auditory, visual, and proprioceptive stimuli, grip strength , and motor activity. A functional observational battery was designed to evaluate the response of the animals in home cage and open field conditions.At the end of week 13 (control and treated groups) and week 17 (recovery groups), all rats were fasted overnight. Blood samples were collected from retroorbital sinus under ether anesthesia for haematology and blood biochemistry using potassium EDTA (1.5 mg/mL) and sodium heparin (200 IU/mL) as anticoagulants, respectively.μL of 3.8% solution of sodium citrate per mL of blood). Blood samples were centrifuged at 3000 rpm for 15 min.Haematological parameters estimated  included haemoglobin (Hb), erythrocyte count (RBC), reticulocyte count (Rt), haematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), platelet count (PLT), and total white blood cells (WBCs). Differential leukocyte counts were performed manually from microscopic specimens. Prothrombin time (Pt) was measured using citrate bulb (100 γGT), lactate dehydrogenase (LDH), bilirubin, blood urea nitrogen (BUN), creatinine, total protein, blood glucose, creatinine phosphokinase (CPK), total cholesterol, triglycerides, albumin, calcium, inorganic phosphorous, sodium, potassium, and chloride.The serum biochemistry parameters studied  were alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma glutamyl transferase  were calculated. The following organs and tissues were preserved in 10% formalin and were subjected to histopathological examinations: adrenals, aorta, brain, caecum, colon, duodenum, epididymis, heart, ileum, jejunum, kidneys, liver, lungs, lymph nodes, oesophagus, ovaries, pancreas, pituitary, prostate, rectum, salivary glands, sciatic nerve, spinal cord, skeletal muscle, spleen, sternum with bone marrow, stomach, seminal vesicles, testes, thymus, thyroid, trachea, urinary bladder, and uterus. t-test, Cochran t-test, and Dunnett's test. Statistical significance was set at P < 0.01–0.05. Histopathological observations were tabulated and individual animal score was calculated according to degree and area .The data were evaluated by analysis of variance followed by Student's All animals administered with a single oral dose of 2000 mg/kg of Zigbir® survived throughout the experimental period and did not show any signs of toxicity immediately following dosing and during the observation period of 14 days. The findings of the study did not reveal any major adverse effect on the body weight gain throughout the treatment period. The body weight gain after 7 and 14 days was found to be 16.54% and 28.55% in sighting study and 14.63% and 29.98% in main study, respectively. No major gross pathological changes were observed on necropsy. Based on the results, the median lethal dose for Zigbir® was found to be greater than 2000 mg/kg body weight.All the male and female animals from control and different dose levels of Zigbir® survived till the terminal sacrifice and no abnormal clinical signs were noticed throughout the 14-day study period. There were no differences in body weight gain between the control and the treated group rats. Necropsy examination did not show any treatment-related evidence of toxicity.Treatment with Zigbir® at selected doses produced no deaths, adverse clinical signs, or toxic effects in the animals throughout the dosing period of 90 days and the postdosing recovery period of 28 days.During the complete experimental period, male animals from all the treated dose groups and recovery groups exhibited comparable body weight gain with that of respective controls . A reducOphthalmoscopic examination of control and all the treated dose group rats did not show any abnormalities.P < 0.01); MCH, females in the 250 mg/kg group and MCHC, females in the 250, 500, and 1000 mg/kg groups (P < 0.01); HCT, females in 1000 mg/kg recovery dose group (P < 0.05) and increase  and females (P < 0.05); total WBC, males in 500 mg/kg group (P < 0.05); HCT, in 250 mg/kg in males and females and in females at 500 mg/kg (P < 0.01) and in females at 1000 mg/kg (P < 0.05), MCV in females at 500 mg/kg (P < 0.05) compared to control group  and decreased potassium levels in female rats of 250 mg/kg group  of brain and spleen in animals of 250 mg/kg dose group and 500 mg/kg dose group, respectively. The 1000 mg/kg recovery group showed an increase in relative weight (P < 0.05) of adrenals  for Zigbir® in the subchronic oral toxicity study was found to be 500 mg/kg in male and 250 mg/kg in female Sprague-Dawley rats.


Many clinical studies have reported that Buyang Huanwu Decoction (BYHWD) has a protective effect on ischemic heart disease (IHD). In the present study, the protective effect of BYHWD on myocardial ischemia was investigated. Different doses of BYHWD and Compound Danshen Dropping Pills (CDDP) were lavaged to rats, respectively, isoproterenol (ISO) was intraperitoneally injected in to all animals to induce myocardial ischemia except the control group. Electrocardiogram (ECG) of each animal was recorded; activities of lactate dehydrogenase (LDH), creatine kinase (CK) and aspartate aminotransferase (AST) in serum were detected. As the results of ECG showed, pre-treatment with BYHWD inhibited ischemic myocardial injury, and the activities of LDH, CK and AST were lower than those in the myocardial ischemia model group, which suggests that BYHWD rescues the myocardium from ischemia status. To research the potential mechanism, the level of nitric oxide (NO), nitric oxide syntheses (NOS) and inducible nitric oxide syntheses (iNOS), the expression of iNOS and ligand of cluster of differentiation 40 (CD40L) were detected. The results revealed that BYHWD significantly decreased the level of NO, NOS and iNOS in serum. Moreover, BYHWD decreased the expression of iNOS and CD40L in myocardial tissues. These results indicate that the protective effect of BYHWD on myocardial ischemia and mechanism are associated with inhibition of iNOS and CD40L expression. Nitric oxide (NO) is a reactive nitrogen species produced by nitric oxide syntheses (NOS). Basal generation of NO has physiological and homeostatic effects, but high level of NO production is often associated with pathological conditions . A numbeIn recent years, inflammation has been recognized as a major force driving ischemic process. Inflammatory cytokines may damage the vascular endothelial surface directly and lead to ischemia . IncreasIn China, many formulas and extracts can be used to treat IHD, Compound Danshen Dropping Pills (CDDP) is the first formula affirmed by US Food and Drug Administration for its excellent effect on IHD . Buyang Trihydroxymethyl aminomethane (Tris) glycine and sodium dodecyl sulfate (SDS) were purchased from Amresco . Anti-iNOS antibody was purchased from Beijing Zhongshan Jinqiao Biology Corporation (P.R. China). Anti-CD40L antibody was purchased from Wuhan Boster Biology Engineering Corporation . LDH, CK, AST, NO, NOS and iNOS assay kits were produced by the Institute of Nanjing Jiancheng Biology Engineering . Protein extraction reagent (RIPA) kit was purchased from Bioteke Corporation . ISO was purchased from Sigma Biotechnology . CDDP was obtained from Tianshili Pharmaceuticals Company . All other agents used were of the commercially available grade.−1 by a vacuum pump and stored at 4°C until use. CDDP was used here as a positive control drug.BYHWD consists of seven medicinal components, including Milkvetch Root, Chinese Angelica, Szechwan Lovage Rhizome, Red Peony Root, Earth Worm, Peach Seed and Safflower, the components were mixed in order with the ratio of 120 : 6 : 3 : 4.5 : 3 : 3 : 3 (dry weight). All of the herbal components were originally purchased from Xi'an Pharmacy of Beijing Tongrentang, and they were stated above with GAP grade. The drugs were extracted with standard methods according to Chinese Pharmacopoeia . These crude drugs were soaked in distilled water and boiled for 30 min twice, and the drug solution was filtered through a mesh, then the filtrate was concentrated to 3 g mL−1/day) and three BYHWD groups . When the experiment began, BYHWD and CDDP were lavaged to the animals once a day while the control group and the model group were lavaged with saline for 14 days. From the 12th day, all animals except those in the control group received ISO (0.03 g kg−1/day) intraperitoneal injection simultaneously once a day for 3 days, while the control group was injected with saline. At the end of the experiment, animals were anesthetized with intrapentobarbital sodium (0.04 g kg−1/day) by peritoneal injection. After electrocardiogram (ECG) was recorded, blood samples were collected by cardiac puncture and heart tissue samples were excised parallel to coronary sulcus, 3 mm apart from cardiac apex. All samples were frozen in liquid nitrogen immediately for further examinations. The experimental protocol was in accordance with the National Institutes of Health Guide for Care and Use of Laboratory Animals and was approved by the Institutional Animal Care Committee of Xi'an Jiaotong University.Sixty male adult Sprague-Dawley (SD) rats weighing 180–200 g were provided by the Medical Experimental Animal Center of Xi'an Jiaotong University . The rats were divided into six groups randomly: control group, model group, CDDP group  at 4°C overnight, respectively. Then, membranes were washed with TBST and a horseradish peroxidase-linked antibody was employed as a secondary antibody (1 : 1000), the bands of interest were detected using an enhanced chemiluminescent technique. Densities of bands were measured by an image analyzer.To investigate the potential mechanism, the expression of iNOS in myocardial tissues was detected by Western blotting. The total protein of myocardial tissues was extracted following the instruction of RIPA and protein concentration was quantified with a BCA protein quantity assay kit. The same amounts of protein was separated by 10% SDS-polyacrylamide gel electrophoresis (SDS-PAGE) at 4°C, and then the protein was transferred onto microporous polyvinylidene fluoride membranes in running buffer with 20% methanol. After nonspecific sites were blocked with 5% milk-Tris-buffered saline-tween 20 (TBST), membranes were incubated with anti-iNOS antibody (1 : 400) and anti-μm sections were prepared. For detection of CD40L expression, sections were incubated with 0.1 M citrate buffer (pH 6.0) for 30 min at 95°C for antigen retrieval and quenching endogenous peroxidase; then the sections were incubated with horse serum blocking solution for 10 min and treated with rabbit anti-CD40L polyclonal antibody (1 : 100) for 2 h at room temperature. After being washed with 0.01 M PBS containing 0.05% Tween-20, the sections were incubated with a biotinylated secondary IgG antibody, and then the sections were treated with streptavidin peroxidase and aminoethyl carbazole. Finally, the sections were visualized with Olympus BX51 microscopy, and the number of CD40L-positive stained cells in myocardium was counted at a magnification of 200x and the ratio of CD40L-positive stained cells/total myocardial cell was calculated.The myocardial tissues samples were separated from the heart, and were fixed in 10% phosphate-buffered formalin and embedded in paraffin and 5 P < .05 were considered statistically significant.Data are presented as means ± SD. Statistical analysis was carried out with three or more groups using one-way analysis of variance (ANOVA) and Dunnetts' test. The values of −1/day) and CDDP (0.073 g kg−1/day) significantly improved the change of ECG by attenuating the descending of the ST segment . Pre-treatment with BYHWD  and CDDP (0.073 g kg−1/day) could decrease the activities of these enzymes in serum. The AST activity in BYHWD of 25.680 and 12.840 g kg−1/day and CDDP groups was significantly less than the model group, respectively (P  < .01), and the LDH and CK activities in all drug-used groups were also less than those in the model group, respectively   . P  < .01), but, significantly deceased by pre-treatment of BYHWD  and CDDP (0.073 g kg−1/day). Compared with that in the model group, there was a significantly difference in the level of iNOS in all BYHWD and CDDP used groups (P  < .01 or P  < .05); the differences in the levels of NO and NOS were also significant except the BYHWD 6.420 g kg−1/day group (P  < .01)  . P  < .01). Pre-treatment with BYHWD  and CDDP (0.073 g kg−1/day) could decrease the expression of iNOS in a dose-dependent manner. Compared with that in the model group, the iNOS protein expression was significantly decreased (P  < .01) in all BYHWD and CDDP used groups with an exception of the BYHWD 6.420 g kg−1/day group . Similarly, plenty of cells were CD40L-positive stained in BYHWD 6.420 g kg−1/day group and there was no difference in the ratio of CD40L-positive stained cells/total myocardial cells between these two groups. In contrast, the number of CD40L-positive stained cells in the other groups was decreased significantly and there was a statistically significant difference in the ratio of CD40L-positive stained cells/total myocardial cells compared with the model group (P < .01).As shown in BYHWD is a classic traditional Chinese medicine formula has been widely used for therapy of ischemic cerebral disease, such as cerebral ischemia, brain infarction and stroke-induced disability in clinic , 15. SomIn the present study, the protective effect of BYHWD on myocardial ischemia was investigated by measuring the change of ECG, as well as the activities of LDH, CK and AST in serum in a myocardial ischemic animal model induced by ISO. Usually, ECG is a useful parameter for determination of myocardial ischemia in clinic and experiment. There are many changes of ECG after myocardial ischemia, including amplitude of R wave, prolonging of QRS duration, elevating or descending of ST segment and change of T wave , 21. Theβ-adrenergic receptor stimulation can upregulate iNOS expression and increase NO production in the heart, which subsequently markedly enhances formation of reactive nitrogen species/peroxynitrite in the heart, thereby eliciting myocardial apoptosis and potentiating myocardial ischemia/reperfusion injury [NO is a major regulator for cardiovascular system by regulating basal vascular tone, blood pressure and tissue perfusion . There an injury . In accon injury . Selectin injury . In prevn injury . In the Increasing evidence supports that inflammation plays an important role in IHD, including myocardial ischemia or silent myocardial ischemia , and acuIn conclusion, our results suggest that BYHWD has a protective effect against myocardial ischemia induced by ISO in rats, and BYHWD inhibition of the iNOS and CD40L expression in myocardial tissues is the potential mechanism of this protective action. These findings provide a pharmacological basis for the clinical application of traditional Chinese medicine BYHWD in prevention of ischemic cardiovascular disease. However, post-treatment with this decoction whether also could produce a treating effect on myocardial ischemia is little known. It requires further study.This work was supported by the National Natural Science Foundation of China (No. 90709018), and the Key Science Research Project of Xi'an, Shaanxi Province (2006GG06174).


P < 0.001). There was a significant correlation between SUA and Neuropad time to colour change in both groups . There was also a significant positive correlation between SUA and CRP in both groups . In conclusion, SUA levels were higher in T2DM patients with sudomotor dysfunction than those without this complication. The potential role of SUA in sudomotor dysfunction merits further study.The aim of this paper was to assess serum uric acid (SUA) levels in patients with type 2 diabetes mellitus (T2DM) with or without sudomotor dysfunction . We included 36 T2DM patients with sudomotor dysfunction (group A: mean age 63.1 ± 2.6 years) and 40 age-, gender-, renal function- and T2DM duration-matched patients without sudomotor dysfunction (group B: mean age 62.1 ± 3.1 years). SUA was significantly higher in group A ( Diabetic autonomic neuropathy (DAN) is a major cause of morbidity and mortality , 2. A raSerum uric acid (SUA) is being considered as a risk marker of cardiovascular morbidity –9. ElevaDespite the reported association between SUA levels and peripheral neuropathy, the potential association with DAN has not been examined. The rationale for this association is that SUA reflects inflammatory activity , 10, andThe present study included 36 T2DM patients with sudomotor dysfunction (group A) and 40 T2DM patients without sudomotor dysfunction (group B). These groups were matched for age, gender, renal function (assessed by serum creatinine), and diabetes duration. Patient characteristics are presented in Exclusion criteria were age <17 or >75 years, chronic renal failure, PAD, stroke, other potential causes of neuropathy , acute or chronic infections or inflammation, haematological disease, as well as use of statins, anti-inflammatory agents, antibiotics, or any medication that might influence SUA levels  –24 durinSudomotor dysfunction was diagnosed by means of the indicator test Neuropad  . This is1c (HbA1c) was assessed by high-performance liquid chromatography . Urinary albumin was measured by an immunonephelometric method . SUA, serum creatinine, C-reactive protein (CRP), triglycerides (TGs), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were measured by spectrophotometry . Glomerular filtration rate (GFR) was calculated by the Cockroft-Gault formula. Haemoglobin Aμg/min in the absence of uncontrolled hypertension and/or urinary tract infection [2).Smoking was defined as daily consumption of ≥1 cigarette for at least 2 years during the preceding 5 years. In accordance with the seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC7), we defined arterial hypertension as a systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on 3 separate occasions  or as annfection  and reconfection . Body mat-test. Qualitative variables were compared by chi-square (after Yates' correction when appropriate). Correlations between Neuropad time to colour change and/or biochemical variables  were evaluated by Spearman's coefficient (rs). Data were expressed as mean ± standard deviation (SD). A 2-tailed P ≤ 0.05 was considered significant.Statistical analysis was performed using the SPSS  version 13.0. Normally distributed quantitative variables were analysed by unpaired 1c), renal function (assessed by serum creatinine and GFR), and frequency of diabetic complications other than neuropathy (P < 0.001). The same was observed for CRP  and TGs , but not for TC , LDL-C , and HDL-C .There were no differences between the 2 groups in demographic characteristics, glycaemic control . This correlation was observed both in group A  and in group B . Furthermore, there was a significant positive correlation between SUA and CRP , which was also observed both in group A  and in group B .Overall, there was a significant positive correlation between SUA and Neuropad time to colour change  but not in group B . Moreover, there was a significant negative correlation between SUA and HDL-C in group A  but not in group B . SUA did not correlate with TC  or LDL-C . There was no correlation between SUA and HbA1c in either group .A significant correlation between SUA and TGs was observed in group A . This correlation was observed both in group A  and in group B . SUA also correlated negatively with GFR . This correlation was observed both in group A  and in group B .Overall, there was a significant positive correlation between SUA and serum creatinine , as well as age, diabetes duration, and HbAuropathy . Hence, uropathy . This coMoreover, patients with sudomotor dysfunction exhibited significantly higher CRP levels than those without sudomotor dysfunction. There was a significant positive correlation between CRP and SUA levels in both groups and in the entire patient population. An association between neuropathy and CRP has been reported by us  and othe1c.Another finding was the association of sudomotor dysfunction with increased TGs and reduced HDL-C. We have previously shown that peripheral neuropathy is associated with increased TGs and TC, but not HDL-C, in T2DM . DespiteThe limitations of the study include that it was not prospective, and thus the potential role of SUA in the development of sudomotor dysfunction could not be examined. Secondly, we assessed a relatively small number of patients and they were recruited in a specialist unit. Therefore, caution is needed before applying our results to the general T2DM population. Furthermore, Neuropad has not yet been established as the gold standard for the assessment of sudomotor dysfunction. However, the more sophisticated modalities, such as the quantitative sudomotor axon reflex test, are only available in a handful of specialised centres across the world and are far too cumbersome to use in clinical practice . NeuropaOur results may have the following practical implications. T2DM patients with sudomotor dysfunction exhibit significantly higher SUA than those without. SUA levels are elevated in association with the severity of sudomotor dysfunction and they are associated with increased CRP and dyslipidaemia. Based on these findings, SUA may be considered a potentially useful additional marker for sudomotor dysfunction. This role should be discussed in the context of the emerging evidence for the contribution of inflammation , 31, 32,In conclusion, SUA levels are higher in T2DM patients with sudomotor dysfunction compared with those without this complication. A significant positive correlation was observed between SUA and the severity of sudomotor dysfunction. Furthermore, SUA levels are associated with CRP. In subjects with sudomotor dysfunction, SUA also correlates with an adverse lipid profile. The present findings suggest that prospective studies should further examine the contribution of SUA to the development of sudomotor dysfunction.


The objective of this study was to investigate the effect of length of smoking cessation and clinical / demographical factors on the rate of emphysema progression and FEV1-decline after follow-up were assessed by analysis of variance adjusting for age, height, baseline pulmonary function and emphysema severity, packyears, years in study and respiratory symptoms. The quitted ≥5 group was used as reference.3,670 male smokers with mean (SD) 40.8 (17.9) packyears underwent chest CT scans and pulmonary function tests at baseline and after 1 and 3 years follow-up. Smoking status  was noted. Rate of progression of emphysema and FEV1 was 3.4 (0.73) L or 98.5 (18.5) % of predicted. The group quitted ‘>5 years’ showed significantly lower rates of progression of emphysema compared to current smokers, 1.07% and 1.12% per year, respectively (p<0.001). Current smokers had a yearly FEV1-decline of 69 ml, while subjects quit smoking >5 years had a yearly decline of 57.5 ml (p<0.001).Median (Q1-Q3) emphysema severity,<-950 HU, was 8.8 (5.1 – 14.1) and mean (SD) FEVQuit smoking >5 years significantly slows the rate of emphysema progression and lung function decline.http://www.trialregister.nl with trial number ISRCTN63545820.Registered at  Chronic obstructive pulmonary disease (COPD) is a common pulmonary disease with an estimated prevalence of 8.9% worldwide . CurrentRegarding emphysema progression in smokers, Suki et al. launched the hypothesis that the smoking related inflammation is not the only culprit, and that mechanical factors also play a role . These mAt a cross-sectional level it has been reported that CT-quantified emphysema is associated with demographical and clinical factors and an increasing number of studies report on effects of smoking habits on CT-quantified emphysema at a cross-sectional level -11. HoweThe Dutch-Belgium lung cancer screening trial included a large number of relatively healthy, but heavy current and former smoking subjects, at risk for developing COPD . A consiThe included subjects were part of a lung cancer screening trial, the NELSON trial ,13. MaleA chest CT scan was performed at least three times in all subjects: year 0 (at start study), year 1 and year 3. In addition, in a number of subjects ‘in between’ scans were made for follow-up of suspect nodules to exclude growth of these nodules which were also included. All included subjects underwent pulmonary function testing (PFT) at baseline. A random sample of approximately two out of three also underwent follow-up (PFT), see Figure http://www.trialregister.nl . Written informed consent was obtained from all subjects.The NELSON trial was approved by the Dutch Ministry of Health and by the institutional review boards of the participating centres. The NELSON trial is registered at The CT protocol has been described in detail before and a more detailed description is also reported in the Additional file 1 and FEV1/ forced vital capacity (FVC) [1/FVC and FEV1 served to assess whether airflow obstruction was present (if FEV1/FVC <70%) and to determine the baseline GOLD stage [Pulmonary function tests (PFT) were performed in year 0 and 3 with standardized equipment according to American Thoracic Society guidelines including FEVty (FVC) . BronchoLD stage .Mean and standard deviation (SD) values were calculated for normally distributed data and median values and inter quartile range (Q1-Q3) for non-normally distributed data. Distribution of normality was checked visually by Q-Q plots.Baseline data were evaluated using analysis of variance or χ -test, wh1 decline was analyzed in the same way as the emphysema progression. P-values ≤0.05 were considered significant. Statistical analyses were performed via SPSS20 .The variable of interest was the ‘percentage lung volume <-950 HU’ and as this is a log-normal distributed parameter we applied a log (ln) transformation first. Smoking status at enrolment of the study  was the main explanatory factor. To assess whether the progression of emphysema differed between these smoking groups, the interaction between the smoking status and ‘time of observation’ was the next relevant factor. The quitted ≥5 years group was used as a reference. We adjusted for presence of respiratory symptoms , packyears of smoking, baseline GOLD stage, study center, height and age at start study. The FEV1/FVC >70%, but there were no differences in airflow obstruction prevalence between the four smoking groups (p= 0.233). Also no significant differences in FEV1 and FEV1/FVC were present between the four smoking groups . Of the 3,670 subjects included a random sample of 2,220 also underwent follow-up pulmonary function testing, see Figure Baseline demographics and lung function test outcomes are shown in Table The effect of the significant parameters on % lung volume <-950 HU are given in Table The median (Q1-Q3) time of observation was 3.0 (2.9 – 3.1) years. All factors in the model significantly influenced  the severity of emphysema, except for study center (p=0.619).Table The interaction between ‘smoking group’ and ‘observation time’ indicates that the development of emphysema differed between these groups p<0.001). Only the current smokers differed from the reference group (= ≥5 years quitters) (p<0.001): the additional yearly increase per year is 1.05 . The annual FEV1 decline for all subjects (irrespective of smoking status) was 57.5 ml/year , with an additional yearly decline per of 11.5 ml (p<0.029). So current smokers faced a total FEV1 decline of 69 ml/ year (57.5 ml + 11.5 ml), see Figure The mixed model analysis showed that all investigated factors significantly influenced the level of FEV1-decline was not significantly correlated to the emphysema progression over the observation time .The FEV1 decline reduced with increasingly longer stopped smoking duration. However, even in long-term quitters the lung function decline was higher as expected compared to normal lung function decline. Although we found a significant effect of smoking cessation on emphysema progression, the size of the effect was not as high as we expected or hoped for. Our data thus seem to confirm the hypothesis of Suki et al who proposed that the initial inflammation is believed to permanently damage / weaken the collagen fibers with subsequent mechanical failure [The results show that in this large cohort of heavy current and former smokers, the progression of emphysema was lower in >5 years quitters compared to current smokers. The FEV failure . It coul1-decline need some time to diminish. A large study in male UK doctors reported it took ~1 year before all COPD-related mortality rates declined [The effect of smoking cessation on emphysema progression and lung function decline differ, i.e. there was a larger effect on lung function. It may be that reduction of emphysema progression takes more time. Smoking related inflammation should have dampened during our long non-smoking follow-up period of 5 years. After smoking cessation, the pathological processes leading to the accelerated FEVdeclined . Two crodeclined ,24. Togeet al. found that, after 2 year of follow-up, current smokers showed significantly stronger emphysema progression than former smokers [1/FVC and FEV1 values existed between the former and current smokers. Furthermore, they did not take the length of smoking cessation into account. Soejima et al. found no significant differences in emphysema progression between former and current smokers after a five year follow-up [Only a few other studies longitudinally examined the effect of smoking status on emphysema progression. Bellomi  smokers . The desollow-up . A drawbollow-up . They st1 decline than continuous smokers [1 decline was 62 ml in continuous smokers, and 31 ml in quitters. In our cohort this was slightly higher, namely 69 and 57.5 ml/ year, respectively. There are some important differences between our study and the LHS. Firstly, the LHS included subjects with COPD, while the vast majority of our subjects had no COPD. The population studied in the LHS was relatively young, with a mean age below 50 years, but with the same exposure to tobacco as our population (~40 packyears). The LHS thus included younger smokers with an apparent increased COPD susceptibility.Our results expand / confirm the outcome of e.g. the Lung Health Study (LHS), a study investigating the effect of smoking cessation in COPD subjects which found that quitters had a considerably lower FEV smokers . The aveAs expected we found the tissue density in ex-smokers to be lower compared to current smokers . This isA positive point of our study is that we included a large sample of heavy smoking subjects selected from the general population and at risk to the develop COPD, rendering our results applicable to the vast number of so-called ‘healthy smokers’. Especially this group is of interest because smoking cessation is the most effective intervention and may prevent progression to COPD. Secondly, emphysema was quantified fully automatic by soft-ware packages, free from inter- and intra-observer variability.This study also has some limitations. Firstly, smoking cessation was self-reported. Some subjects could have restarted smoking during the observation period; however this only would dilute the reported effects of the length of smoking cessation. So we expect to underestimate true effects. Secondly, no females were included in our study: previous research showed that females benefit more from smoking cessation which may imply that women may have less emphysema progression after smoking cessation ,29. It iIn conclusion, we have showed that smoking cessation for ≥5 years decreased lung function decline when compared with current smokers. However, the effect was not as high as expected giving support to the hypothesis that long term smoking starts a unstoppable cascade of tissue damaging. Nonetheless, our results emphasize on the benefits of smoking cessation, regardless of being a heavy smoker.COPD: Chronic obstructive pulmonary disease; CT: Computed tomography; FEV1: Forced expiratory volume in one second; FVC: Forced vital capacity; GOLD: Global Initiative for Chronic Obstructive Lung Disease; HU: Hounsfield unit; LLN: Lower limit of normal; LHS: Lung Health Study; MEF5: Maximum expiratory flow at 50% of FVC; mL: Milliliter; NELSON: Dutch abbreviation for Dutch-Belgian Lung Cancer Screening Trial Perc15, CT derived emphysema severity measure representing the Hounsfield units (HU) point below which 15% of all voxels are distributed.; PFT: Pulmonary function tests; Q1-Q3: 25th – 75th percentile; SD: Standard deviation.DS Postma received funding for research from AstraZeneca, GSK, Nycomed. Travel to ERS or ATS has been partially funded by AstraZeneca, GSK, Chiesi, Nycomed. DS Postma has been consultant to AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Nycomed, TEVA. The other authors state that they have no conflicts of interest.FMH and PZ were responsible for the concept and design of the study and the statistical analyses and are guarantor of the paper. BG was responsible for the quantification of emphysema. HB, HG, DP,JL, HK, MO and PJ assisted in designing the study and writing of the manuscript. All authors contributed to writing and all approved the final version of the manuscript.Results when using Perc15 and %<-910 as emphysema measurement.Click here for file


Since the detection of MRSA CC398 in pigs in 2004, it has emerged in livestock worldwide. MRSA CC398 has been found in people in contact with livestock and thus has become a public health issue. Data from a large-scale longitudinal study in two Danish and four Dutch pig herds were used to quantify MRSA CC398 transmission rates within pig herds and to identify factors affecting transmission between pigs.SIS-)model, which resulted in values of the reproduction ratio (R0) varying from 0.24 to 8.08. Transmission rates were higher in pigs treated with tetracyclins and β-lactams compared to untreated pigs implying a selective advantage of MRSA CC398 when these antimicrobials are used. Furthermore, transmission rates were higher in pre-weaning pigs compared to post-weaning pigs which might be explained by an age-related susceptibility or the presence of the sow as a primary source of MRSA CC398. Finally, transmission rates increased with the relative increase of the infection pressure within the pen compared to the total infection pressure, implying that within-pen transmission is a more important route compared to between-pen transmission and transmission through environmental exposure.Sows and their offspring were sampled at varying intervals during a production cycle. Overall MRSA prevalence of sows increased from 33% before farrowing to 77% before weaning. Overall MRSA prevalence of piglets was > 60% during the entire study period. The recurrent finding of MRSA in the majority of individuals indicates true colonization or might be the result of contamination. Transmission rates were estimated using a Susceptible-Infectious-Susceptible (Our results indicate that MRSA CC398 is able to spread and persist in pig herds, resulting in an endemic situation. Transmission rates are affected by the use of selective antimicrobials and by the age of pigs. Staphylococcus aureus (MRSA CC398), referred to as livestock-associated (LA), was found in pigs and in people in contact with pigs[In 2004, a distinct clone of methicillin resistant ith pigs. Variousith pigs.Antimicrobial resistant microorganisms in livestock become a public health issue when resistant organisms or resistance genes can transfer from livestock to humans. The role of animal populations in the transmission of microorganisms to humans is not only dependent on the possibility of transmission from animals to humans, but also on the possibility of transmission between animals.The primary route of MRSA transmission between humans seems to be direct contact with individuals carrying MRSA,9. HowevR0), which is an essential parameter in management of diseases. R0 is defined as the average number of secondary cases caused by one typical infectious individual during its entire infectious period in a completely susceptible population, and is often used as a quantitative measure of transmission[R0 has a threshold value of 1; if R0 > 1, minor and major outbreaks can occur and an endemic situation can be established and maintained, whereas when R0 < 1 an infection does not spread and will not become endemic, i.e. the infection will fade out[Transmission can be measured in longitudinal field studies and experiments, and can be expressed with the reproduction ratio  selected from a Danish pilot study, and fouSows and their offspring were sampled six times during a production cycle Table. Nasal sIn total, 63 sows and their offspring were included in the study. The number of sows and piglets at each sampling moment varied depending on the number of pigs born alive and/or on movement or death of pigs. After weaning, sows returned to the breeding compartment and were omitted from further sampling. The cohorts of pigs were monitored until slaughtering time. Some pigs were lost for follow up due to sorting and mixing of pigs to other compartments. In one Dutch herd (NL1), no samples were collected at the last two sampling moments, because the pigs were moved to another location.The study protocol was in accordance with the Dutch Law on Animal Health and Welfare and discussed with the Animal Welfare Officer of Wageningen University. The distress was considered below the European injection criterium and therefore no further approval of the Animal Welfare Commission was needed. Informed consent was obtained from each participating farmer.Samples were enriched using Mueller Hinton Broth with 6.5% NaCl (MHB+). Nasal, vaginal and rectal swabs were placed into 5–10 ml MHB+, environmental wipes into 100 ml MHB+. After 18 h of aerobic incubation at 37°C, a loop-full of MHB + was spread onto a chromogenic MRSA Brilliance agar . One suspected colony per sample was confirmed to be MRSA CC398 by PCR[At each sampling moment, prevalences of positive individuals were calculated. An individual was considered positive if either one of the swabs  tested positive for MRSA. The exact confidence intervals (exact 95% CI) for these prevalences were calculated based on the binomial probability function (PROC FREQ).SIS) model[I) if either one of the swabs tested positive for MRSA. Pigs were classified susceptible (S) if all swabs tested negative for MRSA. New born piglets were assumed to be MRSA negative, thus susceptible, at birth. Three sources of MRSA for a susceptible pig were allocated in our study: i) infectious individuals, including sows, within the pen; ii) infectious individuals, including sows, within the compartment (but not in the same pen); and iii) the environment of the compartment. The term total infection pressure (IP) was introduced and defined as the sum of the proportion of infectious pigs (piglets + sows) within the pen (IP within the pen), the proportion of infectious pigs (piglets + sows) within the compartment, but not in the same pen (IP other pens), and the proportion of positive environmental wipes (IP environment).A susceptible-infectious-susceptible (S) model was usedSIS-model can then be represented in FigureThe β is the transmission parameter, defined as the number of secondary cases (C) out of a number of susceptible individuals (S) caused by a certain infection pressure (IP) during each time interval between samplings (Δt). The number of new cases (C) per time interval (Δt) depends directly on β, S and IP; infectious individuals (I) become susceptible again at recovery rate α. C, I, S and Δt were determined per pen. Underlying assumptions were that within a pen (1) all pigs were randomly in contact, (2) susceptible and infectious individuals were homogenous groups, i.e. all individuals were equally susceptible or infectious, and (3) infectious individuals were equally infectious over time.In this model, Δt depends on the transmission rate β and the infectiousness present in their surroundings which we defined as IP. The probability for each piglet to become MRSA positive is therefore equal to:The probability for each piglet to become MRSA positive during a time period C) in a period Δt follows a binomial distribution with parameterS, the number of susceptible individuals  at the start of each time period (Δt). Consequently, the relation between the expected number of cases per unit of time (E(C)) and transmission rate β, IP and the number of susceptibles is as follows :IP ·Δt) as offset variable, C as the number of new cases, and S as the number of trials in the binomial process. Use of such generalized linear models using an offset as explanatory variable on infectious disease data is described by Becker[Δt is presented in the following basic statistical model:Our data (summarized in Tabley Becker in more β) gives the transmission parameter β, that denotes the transmission per day. The reproduction ratio R0 can then be calculated by multiplying β with the length of the infectious period (1/α). We assumed 17.4 days to be the length of the infectious period. This was based on the average length of the infectious period observed in a transmission experiment[Exponentiation of the estimated parameter log , as these antimicrobial classes select 100% for MRSA CC398 and willData from Denmark and The Netherlands were analysed separately and in combination. First, analysis was done without explanatory variables to estimate a basic transmission parameter Table. SecondlP > 0.05. To estimate solely the herd effect, i.e. without explanatory variables, herd was included in the basic model as random effect using an exchangeable covariance structure (PROC GENMOD)[In bi- and multivariable analysis two-way interactions between variables were tested for significance and removed if  GENMOD). Herd efOverall MRSA prevalence of sows increased from 33.3% (exact 95% CI: 22.0-46.3%) before farrowing (moment 1) to 58.8% (exact 95% CI: 46.2-70.6%) after farrowing (moment 2) and to 77.3% (exact 95% CI: 65.3-86.7%) ~ 3 weeks later, just before weaning (moment 3). All sows in herd NL4 tested MRSA negative, whereas all sows in herd DK1 tested MRSA positive at all sampling moments  in new born piglets (moment 2) to 77.8% (exact 95% CI: 74.6-80.7%) ~ 3 weeks later, just before weaning (moment 3). Post-weaning, MRSA prevalence of pigs was 79.6% (exact 95% CI: 76.2-82.8%) at moment 4 and 86.6% (exact 95% CI: 83.2-89.5%) at moment 5. In the finishing compartment, just before slaughter, MRSA prevalence was 69.6% (exact 95% CI: 64.9-74.1 (TableP < 0.0001) if their dam was MRSA positive before farrowing compared to MRSA negative dams. MRSA prevalence in pigs from positive dams was 84% versus 48% from negative dams. In Danish herds, MRSA prevalence in pigs from positive dams was 78% versus 73% from negative dams. Combining data from all herds, 81% of new born pigs from MRSA positive sows were positive after birth, whereas 50% of pigs from MRSA negative sows were positive at that time (P < 0.0001).New born piglets (moment 2) in Dutch herds were more often MRSA positive  for Dutch pigs and 1.88 (95% CI: 1.59-2.22) for Danish pigs. Including data from pre-weaning pigs only, resulted in a slightly higher R0-value for Dutch pigs , whereas the R0-value for Danish pigs did not change . Analysis on data from both countries resulted in intermediate R0-values (TableTableP < 0.0001 for Dutch data and P = 0.10 for Danish data) and the relative proportion of IP within the pen compared to the total IP (pIP: P < 0.0001 for Danish and Dutch data), and no significant interaction effect (P > 0.05). The effect of pIP was very large, especially in Danish herds. For Danish pigs, R0 was 0.02 (95% CI: 0.00-0.07) without use of risk antimicrobials and pIP at its minimum (i.e. 0), and 0.03 (95% CI: 0.00-0.16) with use of risk antimicrobials and pIP at its minimum. When pIP was at its maximum, R0-values were infinitely large both without and with use of risk antimicrobials (R0 = 121076 (95% CI: 307.31-4.77E + 07) and 1760410 (95%CI: 287.92-1.08E + 08), respectively). For Dutch pigs, R0 was 0.62 (95% CI: 0.45-0.84) without use of risk antimicrobials and pIP at its minimum, and 1.54 (95% CI: 0.84-2.83) with use of risk antimicrobials and pIP at its minimum. When pIP was at its maximum, R0-values were 3.28 (95% CI: 1.43-7.49), and 8.17 (95%CI: 2.65-25.22) for without and with use of risk antimicrobials, respectively , and the highest R0 when risk antimicrobials were used and pIP at its maximum . Average pIP was 0.32 (SD = 0.21) for Dutch herds and 0.27 (SD = 0.08) for Danish herds ; interaction effects were not significant (P > 0.05). FigureR0 for pIP-values between 0 and 1. R0 was lowest at 0.24 (95% CI: 0.18-0.31) when no risk antimicrobials were used in post-weaning pigs and pIP = 0. R0 increased to 0.60 (95% CI: 0.34-1.06) when risk antimicrobials were used in post-weaning pigs and a minimal pIP. R0 was above 1, though not significant , when risk antimicrobials were used in pre-weaning pigs and a minimal pIP, and below 1, though not significant,  when risk antimicrobials were used in post-weaning pigs and a minimal pIP. R0 increases with increasing pIP. Given a maximal pIP of 1, R0 was 1.22 (95% CI: 0.60-2.48) without using risk antimicrobials in post-weaning pigs and significantly above 1, i.e. 3.12 (95% CI: 1.15-8.46) when risk antimicrobials were used in this age-group. In pre-weaning pigs, R0-values were significantly above 1; R0 was 3.16 (95% CI: 1.14-8.82) when no risk antimicrobials were used, and highest with use of risk antimicrobials .Multivariable analysis of all Dutch data showed significant effects of all three variables, ab, age and pIP . A rapid increase in prevalence in this herd was seen after weaning, despite the fact that no risk antimicrobials were used during that time interval and that no positive dust samples were found at the first sampling moment in the weaning compartment. In a longitudinal study on an antimicrobial-free Canadian pig farm, a similar increase in MRSA prevalence was observed around the time of weaning. Co-mingThe recurrent finding of MRSA in the majority of sampled individuals either indicates true colonization or might be the result of contamination. To distinguish between true colonization and contamination, MRSA positive pigs should be placed in a clean environment individually for a longer time.SIS-model to describe the transmission of MRSA within herds, assuming that infectious pigs stop shedding after a while and become susceptible again. This assumption was based on the fact that most humans are intermittent carriers[We used a carriers and on dcarriers.SIS-model without explanatory variables, was significantly above one, indicating a high probability of transmission and persistence within a pig herd[i.e. the period in the finishing pig compartment, was much longer (> 10 weeks). During this period, more than one infection might have occurred in one individual, whereas our method only counts one. This implies a potential underestimation of transmission rates. Based on the prevalence in pigs just before slaughter (70%), the reproduction ratio can be estimated using R0 = 100/[R0 = 1.24), indicating an underestimation, however, it is similar to the estimated reproduction ratio from a transmission experiment[The basic reproduction ratio, based on a pig herd. The reppig herd, the envvalence), resultiTransmission rates were higher when tetracyclins and β-lactams were used which might be explained by a selective advantage of MRSA CC398 as compared to susceptible strains present in the nasal microbiota when these antimicrobials are used. An experimental study investigating the effects of zinc and tetracycline on MRSA counts in nasal samples of pigs, showed higher counts in treated animals than in untreated animals, which seems to confirm a selective advantage of MRSA CC398 caused by both compounds. The effThe proportion of susceptibles and therefore, potentially new cases, was relatively high among pre-weaning pigs compared to post-weaning pigs; we actually assumed all new born piglets to be MRSA negative, and thus susceptible, before birth. MRSA prevalence in post-weaning pigs was much higher, leaving fewer susceptibles to become a case and thus estimation of transmission rates was based on less information in this age-group. Thus the power of the comparison is lower. Nevertheless, the available data indicated that transmission rates in pre-weaning pigs are significantly higher than in post-weaning pigs. This might be explained by the presence of the sow, which might be a primary source of MRSA for the new born piglets. An association between MRSA status of the sow prior to farrowing and that of the offspring just after birth was shown in our study, and was found in a longitudinal study on a Canadian pig farm as well. PerinatThe increased transmission rates observed in correspondence with the relative increase of the infection pressure within the pen implies that transmission through direct contact with pen mates is an important transmission route. More quantitative information on transmission rates within and between pens and the role of environmental contamination can be obtained by transmission experiments.R0, e.g. antimicrobial use, might be confounded by other effects. Although herd effect accounted for only 0.06% of the variance in the multivariable analysis, it was not possible to distinguish the herd effect from an unconfounded estimate of the exposure effects. Prudence is therefore called for in drawing conclusions from these associations.Since only 4 to 6 farrow-to-finish herds were included in the estimation of transmission rates, including some herds with very high prevalences leaving just a few trials for parameter estimation, the results might not be representative for the international pig herd population. Moreover, the observed association between explanatory variables and e.g. by prudent antimicrobial use, all-in all-out procedures and hygiene barriers between age groups.In conclusion, introduction of MRSA in a fully susceptible population most probably leads to transmission and an endemic situation where direct contact between animals is the most important route of transmission. Control programs should therefore focus on (1) prevention of introduction into a herd, and (2) prevention of transmission within a herd, The authors declare that they have no competing interests.MJ, EG, AG, LG, PB, JPN, PW and EB contributed to the design of the longitudinal field study. EB, PB, PW and CEG coordinated and performed the studies. EG, NV, MJ and EB analysed the data. EB, EG and CEG drafted the manuscript. All authors read, revised and approved the final manuscript.EB’s current position is at Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, The Netherlands


Background. It is well acknowledged that glucocorticoid (GC) replacement can unmask diabetes insipidus (DI) in subjects with hypopituitarism. Objective. To increase the awareness and monitoring for transient and symptomatic DI in children with partial hypopituitarism during periods in which increased GC needs are required. Methods/Case. A 2-month-old female infant with septo-optic dysplasia  developed transient DI during 2 separate episodes of stress  when stress dosing of GC (25 mg/m2/day) was instituted. Conclusion. Children not diagnosed with DI during initial evaluation for hypopituitarism may benefit from rescreening of serum sodium levels during acute periods of stress that demand "stress" GC dosing. This will permit treatment and/or increased vigilance for ensuing permanent DI. Septo-optic dysplasia (SOD) is a malformation syndrome in which at least 50% of children have associated hypopituitarism , 2. ThisHere we present an infant in whom DI was not present during maintenance GC replacement but was unveiled during two episodes in which "triple stress GC dosing" was accompanied by temporary DI.2/day).Patient is a 2-month-old female with SOD diagnosed in the newborn period secondary to hypoglycemia and hypotonia. SOD was confirmed by both MRI and ophthalmologic exam. Hypopituitarism manifested with central hypothyroidism and hypoadrenalism such that her medications at presentation included thyroid supplementation (37.5 mcg or 10 mcg/kg/day) and hydrocortisone (8 mg/m2) at the OSH and then transferred to our PICU. Repeat serum Na was then 155 mmol/L, and she was treated with a normal saline intravenous (IV) fluid bolus and then maintained on D5.5 NS at maintenance for a 12-hour period. Her Na rose to 160, and she was given DDAVP . During this time she continued GC stress dosing of 2.3 mg hydrocortisone every 8 hours , dehydration, and hypothermia . Oral feeds continued without DDAVP and, after 17 hours, her Na level again rose to 157 mmol/L. A second lower dose of DDAVP (effective dose of only 0.5 mcg) was then given as she appeared dehydrated and was tachycardic. Accurate urine output was not obtained as patient had not been catheterized. Surprisingly, this second dose resulted in an acute drop in her Na to 130 mmol/L over twelve hours (2.25 mmol/hour) and was accompanied by seizure activity. The patient was on oral feeds by this time, with IVF at 2 mL/hr to maintain IV patency. Her serum sodium levels normalized to 136–142 mmol/L over the following 18-hour period with fluid restriction.SG of 1.014, arguing against fulminant DI.Once normothermic, she was returned to her maintenance GC dose, and, of note, no subsequent doses of DDAVP were required during this 6-day period. At this time, a modified water deprivation test was performed and, at time of 15 hours, the patient's serum Na remained normal at 141 with a U2/day) with repeat blood and urine cultures being negative. Again, her serum Na increased to a peak of 163 mmol/L and was accompanied by a USG of 1.005, a weight loss of 1.72 kg as well as an AVP level that was notably undetectable at <0.6 pg/mL , supporting the diagnosis of another episode of "unmasking" of DI. Consequently, DDAVP was re-instituted, albeit at a markedly conservative dose of 2.50 mcg of IN preparations given orally (effective dose of 0.25 mcg) that successfully maintained her Na levels within a range of 145–155 mmol/L. Interestingly, she has been maintained on this dose since that time, given that her "transient" episodes seen during the increased GC exposure ultimately progressed to permanent, although likely "partial," DI.A subsequent febrile episode (temp 38.6°C) led to reinstitution of stress GC dosing  [Although the "unmasking of DI" upon institution of GC replacement in children with pituitary insufficiency is well recognized, the mechanism of the sequelae is less well delineated. Both a GC-induced decrease in AVP release as well as inhibition of action at the level of the kidney has both been reported . For exaow (GFR) . SG. Interestingly, after the continued need for stress GC dosing, permanent, although likely still partial, DI evolved with low dosing requirement, suggesting that we may have unmasked the progression of natural development to DI that was occurring but was brought to medical attention during her periods of increased GC requirements. To date, no cases have been reported in which DI was induced only when greater than maintenance dosing of GCs were given. In our patient, DI was unmasked initially during a presumed viral illness only during episodes where stress dose GCs were required, suggesting a mild/partial DI, especially given the markedly low dose of DDAVP required to control her DI despite unmeasurable endogenous AVP levels during period of elevated serum Na levels and low USG or osm along with body weight monitoring) during episodes of acute stress and concomitant increased GC dosing may, indeed, be clinically relevant by unveiling a partial/complete DI. Such vigilance could then obviate symptomatic DI, particularly in a young infant or in a child whose thirst mechanism may be either difficult to assess (since feeds are still formula) or may be impaired. It is also important to note, since DI could still be partial as it was in our patient, that the dosing of DDAVP is done conservatively and only when the patient has clinical signs of DI . Finally, the DI should also be viewed as transient/episodic until permanent DI has been declared.This case supports, therefore, that, in children who have not been diagnosed with DI during their initial evaluation for hypopituitarism , rescreening of serum Na levels (along with parallel UAVP:Arginine vasopressinDDAVP:Desmopressin acetateDI:Diabetes insipidusED:Emergency DepartmentGC:GlucocorticoidHC:Hydrocortisoneosm:OsmolarityOSH:Outside HospitalPICU:Pediatric Intensive Care UnitSOD:Septo-optic dysplasiaSG:UUrine specific gravity.


The influence of prosthesis-patient mismatch (PPM) on survival after aortic valve replacement (AVR) remains controversial. In this study, we sought to determine the effect of PPM on early (≤30 days) and late mortality (>30 days) after AVR or AVR combined with coronary artery bypass grafting (AVR with CABG).2/m2 and patients were divided into two groups based on the existence of PPM. Cumulative probability values of survival were estimated with Kaplan-Meier method and compared between groups using Breslow test. Univariate and multivariate independent predictors of early mortality were identified using logistic regression. Cox proportional-hazard regression analysis was used to determine univariate and multivariate independent predictors of late mortality.Between January 1998 and March 2012, 2976 patients underwent AVR (n= 1718) or AVR with CABG (n=1258) at a single institution. PPM was defined as an indexed effective orifice area (EOAI) ≤0.85 cmEarly mortality was 6.7% in the PPM group vs 4.7% in the group with no PPM (p=0.013). Late mortality for the PPM group at 1, 5 and 10 years was 4%, 16% and 43%, respectively. Late mortality for the group with no PPM at 1, 5 and 10 years was 4%, 15% and 33% respectively. Independent predictors of early mortality included age, severely impaired left ventricular (LV) function, endocarditis, renal dysfunction, chronic obstructive pulmonary disease (COPD) and cardiopulmonary bypass (CPB) time. Multivariate independent predictors of late mortality included age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, history of a cerebrovascular accident (CVA), CPB time and a history of previous cardiac surgery. PPM was not an independent predictor of early or late mortality.PPM is not an independent predictor of both early and late mortality after AVR or AVR combined with CABG. Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) occurs when the effective orifice area (EOA) of the implanted valve prosthesis is too small compared to the body surface area (BSA) of the patient . PPM is 2/m2[in vitro EOA values provided by the manufacturers to identify PPM [in vivo EOA values to identify PPM [Several studies have shown that PPM is associated with increased early or late mortality after AVR -6. Other2/m2. Comparitify PPM ,16, whiltify PPM ,17.2/m2 as described by Pibarot and colleagues [In this study, we sought to determine the effect of PPM  on earlThis is a retrospective observational study on consecutive patients. Data were obtained from the institutional database, normally utilized for patient care. Clinical data, echocardiographic data, catheterization data and surgical reports were entered into the institutional database prospectively and analyzed retrospectively. Because standard clinical follow-up check-ups were used and data were collected and analyzed anonymously, the need for informed consent was waived by the Medical Ethical Committee.Between January 1998 and March 2012, 2976 patients (mean age 68±11 years) underwent AVR (n=1718) or AVR with CABG (n=1258) at a single institution using a mechanical or a stented biological valve prosthesis. Patients who underwent AVR with implantation of a stentless biological valve were not considered. No aortic annular enlargement procedures were performed.Follow-up data concerning mortality were gathered using the databases of health insurance companies. The remaining data that could not be retrieved from these databases were obtained by contacting patients’ general practitioners and if necessary by contacting local government authorities. Nineteen patients were lost to follow-up; mean follow-up was 5.7±3.7 years (range 0.0-14.7 years). Patients lost to follow-up were excluded from our analysis. Late mortality was defined as death occurring later than 30 days after surgery.2/m2 were assigned to the group with PPM and patients with an EOAI >0.85 cm2/m2 to the group without PPM.Based on the EOAI the patients were split into two groups. Patients with an EOAI ≤0.85 cmAll patients underwent surgery using a standard technique. After a median sternotomy the ascending aorta and right atrium were cannulated and normothermic extracorporeal circulation with non-pulsatile flow was instituted. Myocardial protection was obtained using cold crystalloid cardioplegia (St. Thomas solution) or warm blood cardioplegia. According to surgeon’s preference, cardioplegia was administered in an antegrade fashion through the aortic root and/or selectively in both coronary ostia to induce and maintain cardiac arrest. Retrograde administration of cardioplegia was not used. Concomitant myocardial revascularization was performed in 1258 patients. The distal anastomoses were performed before AVR. An overview of implanted prosthetic valve types is shown in Table in vitro values published by each manufacturer) by each patient’s BSA [2/m2[2/m2 and ≤0.85 cm2/m2) (n=330) and severe PPM (EOAI ≤0.65 cm2/m2) was not performed because of the small group size of patients with severe PPM (n=14).PPM was expressed by the EOAI. The EOAI was calculated by dividing the corresponding EOA of each valve type and size  were reported with 95% confidence intervals (CI). Goodness of fit of the final model was assessed with the Hosmer-Lemeshow goodness-of-fit test.Cox proportional-hazard regression analysis was used to determine univariate predictors and multivariate independent predictors of late mortality. Hazard ratios (HR) were reported with 95% confidence intervals (CI).Variables considered as potential predictors for multivariable modeling were selected by univariate analyses (p<0.05) and were subsequently selected by stepwise forward selection, with entry and retention in the model set at a significance level of 0.05. Goodness of fit of the final model was assessed with the Chi-squared goodness-of-fit test.All calculations were performed using a commercially available statistical package . Statistically significant differences were established at p<0.05.2/m2 and were allocated to the PPM group. The remaining 2613 patients with an EOAI >0.85 cm2/m2 were allocated to the group without PPM. Patient characteristics are shown in Table 2, p<0.001), a higher average BSA , but there was no significant difference in average height. In the PPM group significantly more mechanical valve prostheses were implanted , the average cardiopulmonary bypass (CPB) time was longer  and significantly more patients had had previous cardiac surgery . With regard to the distribution of comorbidities between the two groups, only the prevalence of diabetes was significantly higher in the PPM group .After excluding 19 patients lost to follow-up, 2957 patients were analyzed. 1701 patients underwent AVR and 1256 patients underwent AVR with CABG. 344 patients had an EOAI ≤0.85 cmEarly mortality was 6.7% in the PPM group vs 4.7% in the other group (p=0.013).The additive EuroSCORE was 6±3 in both groups (p=0.095). The logistic EuroSCORE was 8.64±9.29 in the group with PPM and 7.66±8.14 in the group without PPM (p=0.146).Univariate predictors of early mortality .Mean follow-up was 5.7±3.7 years (range 0.0-14.7 years). Total follow-up was 16728.6 patient-years. Late mortality for the entire group at 1, 5, and 10 years was 4%, 15% and 37%, respectively.Late mortality at 1,5, and 10 years was 4%, 15% and 33%, respectively for the group without PPM and 4%, 16% and 43% for the PPM group.The results of Cox regression analysis for late mortality are shown in Table Univariate analysis revealed the following predictors of late mortality: age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, COPD, history of CVA, the use of a mechanical prosthesis, concomitant CABG, CPB time, aortic cross-clamp time, previous cardiac surgery and PPM.Multivariate analysis revealed the following independent predictors of late mortality: age, diabetes, severely impaired LV function, PVD, renal dysfunction, COPD, a history of CVA, CPB time and previous cardiac surgery. PPM was not an independent predictor of late mortality at multivariate analysis. Goodness of fit of the final model was assessed with the Chi-squared goodness-of-fit test: p<0.001.Figure The most important finding of this study is that PPM is not identified as an independent predictor of early or late mortality after AVR or AVR with CABG. Table in vivo EOA values [in vitro manufacturer’s EOA [in vitro EOA values provided by the manufacturers, since these values are uniform and publicly available for almost each type of prosthetic valve on the market. In our opinion, preoperative planning requires readily accessible and uniform information of all aortic valve prostheses currently available on the market. Manufacturer’s EOA charts are providing this information and most likely the surgeon would use these values to determine the possibility of PPM.The effect of PPM on early or long-term survival after AVR remains controversial . SeveralA values ,5,17, wher’s EOA ,14,16. WValve prosthesis industry is a highly competitive market. Although most contemporary biological and mechanical prosthetic valve designs have excellent hemodynamic profiles, companies want to distinguish their products with demonstrable specifications. It would be illusory to deny the existence of PPM completely, but marketing may have caused too much attention concerning this topic. Perhaps the issue of PPM is partially an industry driven hype.An important limitation is the retrospective design of this study. Although both study populations were homogeneous for most risk-factors, some baseline patient characteristics were significantly different between the two groups. We were not able to do subgroup analyses of moderate and severe PPM due to the lack of patients with severe PPM. This can be explained by our surgical strategy to implant the biggest valve possible and to use prosthetic valves with optimal hemodynamic profiles in patients with small annular sizes, thus inducing bias. On the other hand it illustrates that severe PPM is extremely rare when using this strategy even without using aortic annular enlargement techniques. Other studies confirm that the incidence of severe PPM is low ,28. In aIn conclusion, our findings indicate that PPM is not an independent predictor for early or late mortality after AVR or AVR with CABG. The outcome of this study puts the importance of PPM once again into perspective.AVR: Aortic valve replacement; BMI: Body mass index; BSA: Body surface area; CABG: Coronary artery bypass grafting; CI: Confidence interval; COPD: Chronic obstructive pulmonary disease; CPB: Cardiopulmonary bypass; CVA: Cerebrovascular accident; EF: Ejection fraction; EOA: Effective orifice area; EOAI: Effective orifice area index; HR: Hazard ratio; LV: Left ventricular; OR: Odds ratio; PPM: Prosthesis-patient mismatch; PVD: Peripheral vascular disease.All authors declare that they have no competing interests.MS participated in the design of the study and helped to draft the manuscript. WB participated in the design of the study and helped to draft the manuscript. MM participated in the design of the study and revised the manuscript. KP made a substantial contribution to acquisition of data and interpretation of data. JD made a substantial contribution to acquisition of data and interpretation of data. AS made a substantial contribution to conception and design of the study, the acquisition and interpretation of data and revised the manuscript. BK made a substantial contribution to conception and design of the study, the interpretation of data, drafting the manuscript and performed the statistical analysis. All authors read and approved the final manuscript.


Research has suggested that adults 40 years old and over are not following eye care visit recommendations. In the United States, the proportion of older adults is expected to increase drastically in the coming years. This has important implications for population ocular disease burden, given the relationship between older age and the development of many ocular diseases and conditions. Understanding individual level determinants of vision health could support the development of tailored vision health campaigns and interventions among our growing older population. Thus, we assessed correlates of eye care visits among participants of the Behavior Risk Factor Surveillance System (BRFSS) survey. We pooled and analyzed 2006–2009 BRFSS data from 16 States . We assessed for the proportion of survey respondents 40 years of age and older reporting having visited an eye care provider within the past two years, two or more years ago, or never by socio-demographic characteristics.Nearly 80% of respondents reported an eye care visit within the previous two years. Using the ‘never visits’ as the referent category, the groups with greater odds of having an ocular visit within the past two years included those: greater than 70 years of age , with college degree (5.2[3.0–8.8]), reporting an eye disease, (4.74[1.1–21.2]), diagnosed with diabetes (3.5[1.7–7.5]), of female gender (2.9[2.1–3.9]), with general health insurance (2.7[1.8–3.9]), with eye provider insurance coverage (2.1[1.5–3.0]), with high blood pressure (1.5[1.1–2.2]), and with moderate to extreme near vision difficulties (1.42[1.11–2.08]).We found significant variation by socio-demographic characteristics and some variation in state-level estimates in this study. The present findings suggest that there remains compliance gaps of screening guidelines among select socio-demographic sub-groups, as well as provide evidence and support to the CDC’s Vision Health Initiative. This data further suggests that there remains a need for ocular educational campaigns in select socio-demographic subgroups and possibly policy changes to enhance insurance coverage. The proportion of persons older than 40 years old in the United States is expected to increase drastically in the coming years . This haThe American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) recommend comprehensive eye examinations by ophthalmologists or optometrists for adults with no signs or risk factors to be conducted as a baseline at the age 40 years -15. CurrThe Behavioral Risk Factor Surveillance System (BRFSS), developed by the Centers for Disease Control and Prevention (CDC), is an ongoing, state-based, random-digit-dialed telephone survey that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury among a non-institutionalized, civilian adult population aged 18 years and older . This stBeginning in 2006, the optional Visual Impairment and Access to Eye Care module was included in the survey to assess prevalence of self-reported visual impairment, eye disease, eye injury, and lack of eye care insurance and eye examination among persons aged 40 years and older. Details about its purpose, sampling methods, data collection, and reporting are available elsewhere .We pooled data from the 2006–2009 BRFSS for all adults aged 40 years and older participating in the Visual Impairment and Access to Eye Care module administered by the following States: Alabama, Alaska, Connecticut, Florida, Georgia, Indiana, Iowa, Missouri, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia and Wyoming . The median survey cooperation rate from 2006–2009 ranged from 72.1% to 75.0% .Participants were asked “When was the last time you had your eyes examined by any doctor or eye care provider?” and responded either within the past month, within the past year, within the past 2 years, 2 or more years ago, or never. We grouped respondents into three outcomes 1) having visited an eye care provider within the past two years, 2) two or more years ago, or 3) never.Age was categorized into four age groups: 40–49, 50–59, 60–69, and > 70 years old. Additional sociodemographic covariates included: gender, race/ethnicity , highest educational attainment , marital status .Participants were also classified based on general health insurance coverage (yes or no), and eye care provider insurance coverage (yes or no). Body mass index (BMI) was based on reported height and weight and was categorized as: (1) neither overweight nor obese [< 25 kg/m2]; (2) overweight [25–29.9 kg/m2]; or (3) obese [> = 30 kg/m2]. Participants were also classified as diabetic or hypertensive if they indicated they were told by a health care professional that they had these conditions.Survey participants reported on far vision difficulties (categorized as dichotomous “little to none” or “moderate to extreme”), near vision difficulties , and their eye disease status based on the respondents affirmation to either having been told by a doctor they had cataracts, glaucoma, or age-related macular degeneration (categorized into yes or no if the respondent indicated they had any of the listed ocular diseases).We analyzed data from individuals who had visited an eye care provider within the past two years, two or more years ago, or never. Prevalence estimates for eye care provider visits and the proportion of participants categorized by frequency of eye care visits across a number of socio-demographic and health-related characteristics are presented in Table All analyses were performed using SPSS 17 Complex Samples for Survey Analysis  to account for multiple stages of sampling, stratification, and clustering. An alpha level of 0.05 was considered statistically significant. All analyses in this study were weighted according to the standard procedures for analyzing sample survey data . For pooThe study population represented an estimated 53.6 million U.S. adults annually from 2006–2009. The prevalence of visiting an eye care provider within the past two years, two or more years ago, or never by sociodemographic characteristics, are presented in Table In the polytomous multiple logistic regression , having graduated from college relative to those who did not complete high school (2.4 [1.4–4.0]), having diabetes (2.2 [1.1–4.8]), being female (2.2 [1.6–3.0]), having general health insurance (1.8 [1.2–2.6]), and having high blood pressure (1.6 [1.1–2.3]).We found significant variation by socio-demographic characteristics and some variation in state-level estimates. Correlates of visiting an eye care provider included: being older (e.g. 70 years of age or older), being female, having higher educational attainment, having general health and eye care insurance, being diagnosed with diabetes or high blood pressure, reporting an eye condition such as cataract, glaucoma, or age-related macular degeneration, and having near vision difficulties. To our knowledge, no previous studies have used multistate-level data to test the association between sociodemographic characteristics and report of eye care provider visit. Our findings are consistent with studies from the Los Angeles Latino Eye Study, which reported that select socio-demographic characteristics are strongly associated with more frequent eye care provider visits among Latinos, for example: age, educational attainment, general health and eye insurance status, and co-morbidities .A visit to an eye care provider within the past two years in this study was associated with a number of variables in our multivariable analysis. Among predisposing variables, older age, female gender, and more education were independently associated with greater use of provider eye care service. These results are consistent with previous research showing that women and older individuals are more likely to use vision health services than their male and younger counterparts . PreviouP < 0.05) were: (1) Having a larger number of chronic conditions, (2) Having near vision difficulties, (3) Having a higher level of education, (4) Being of female gender, and (5) Being of older age.Other factors correlated with greater odds of visiting an eye care provider within the past two years included: having primary ocular disease such as cataract, glaucoma, or age-related macular degeneration, ). These findings are also similar to results from the Blue Mountains Eye Study in Australia, which included clinical eye examinations ; they reWe found some variation in state-level estimates of eye care provider visits. Among respondents attending an eye care provider visit within the past two years, adults from Connecticut and New York had the highest estimates for visiting an eye care provider, while respondents from Missouri and New Mexico had the lowest. Studies suggest that state variation in health care visits is driven by underlying economic and demographic factors, such as the employment makeup in the state , eligibility requirements for public programs such as Medicaid, and the demographic/socioeconomic composition of state residents -22. StatThis study adds to the literature by being the first to describe the association between eye care provider visits and socio-demographic characteristics using recent population-based data across multiple US states. We were also able to identify the contributions of several important variables  to these relationships. Although the BRFSS data have been found to provide valid and reliable estimates as compared with the national household surveys , our stuPublished recommendations by professional organizations for screening and comprehensive eye examinations by ophthalmologists and optometrist have existed for many years -15. HoweThe authors declare that they have no competing interestsAJCM: conceived the study, participated in its design, coordination, performed statistical analyses, and co-drafted the manuscript. EPD: participated in the design of the study, performed statistical analysis and helped with the manuscript draft. BLL: participated in the design of the study, performed statistical analysis and helped with the manuscript draft. KLA: participated in the design of the study, performed statistical analysis and helped with the manuscript draft. KEM: participated in analysis of the study results and helped with the manuscript draft CAF: participated in analysis of the study results and helped with the manuscript draft. MAO: participated in analysis of the study results and helped with the manuscript draft DJL: conceived the study, participated in its design, coordination, performed statistical analyses, and co-drafted the manuscript. All authors read and approved the final manuscript.Support for this study was provided by National Eye Institute grant (R21-EY019096).