Malaria is one of the leading public health problems in sub-Saharan Africa that contributes to significant patient morbidity and mortality. The aim of the study was to investigate adherence to malaria diagnosis and treatment guidelines by private health sector providers and compare their performance against the public private partnership (PPP) status.ideal, acceptable, minor error and major error for both malaria diagnosis and treatment. A chi-square (X2) test was used to test for a statistically significant relationship after the data had been categorized using public private partnership status at P < 0.05.A facility-based retrospective clinical audit was conducted between October 2016 and January 2017 in 11 medium clinics in the West Gojjam zone of the Amhara Region, North-west Ethiopia. Data was extracted from patient medical records using pretested data abstraction forms. Descriptive statistics were employed to present the findings and adherence of health workers against the national and international standards were classified as 2 (1) = 0.0With regards to treatments of malaria cases, the majority 82.9% of Plasmodium vivax cases were managed with ideal recommended treatment (X2 (1) = 0.35, P = 0.55); among Plasmodium falciparum, mixed .One thousand six hundred fifty clinical files were audited. All malaria suspected patients were investigated either with microscopy or rapid diagnostics test (RDT) for parasitological confirmation. The proportion of malaria treated cases was 23.7% (391/1650). Of which 16.6% (274/1650) were uncomplicated, 3.69% (61 /1650) were severe and complicated and the rest 3.39% (56/1650) were clinical diagnosed malaria cases. And the malaria parasite positivity rate was 20.30% (335/1650). All malaria suspected patients were not investigated with ideal malaria diagnosis recommendations; only 19.4% (320/1650) were investigated with acceptable malaria diagnosis (public private partnership (PPP) 19.4%; 176/907; and non-public private partnership (NPPP) 19.38%; 144/743, XThe clinical audit revealed that the majority of malaria patients had received minor error malaria diagnostic services. In addition, only one fifth of malaria patients had received ideal malaria treatment services. To understand the reasons for the low levels of malaria diagnosis and treatment adherence with national guidelines, a qualitative exploratory descriptive study is recommended. In the last two decades, substantial progress has been made in fighting malaria . AccordiGlobally, prompt and effective diagnosis and treatment of uncomplicated malaria cases has been implemented for several decades. This makes it possible for patients to be cured timely, preventing the development of severe malaria and subsequent death –8. The cPlasmodium falciparum and Plasmodium vivax malaria, respectively. The second-line recommendation consist of quinine plus SLD primaquine for the treatment of uncomplicated P. falciparum or mixed or presumed malaria infection, and AL for the treatment of uncomplicated P. vivax malaria. No antibiotics are recommended for malaria case management in Ethiopia [P. vivax malaria cases using primaquine 0.25 mg/kg BW/day for 14 days to be administered under health workers’ supervision only in malaria elimination target districts [The international and national malaria treatment protocols recommend treatment with species-specific anti-malarial drugs. The first-line recommendations for uncomplicated malaria include artemether-lumefantrine (AL), at a total dose of 5–24 mg/kg body weight (BW) of artemether and 29–144 mg/kg of lumefantrine plus 0.25 mg/kg BW single low-dose (SLD) primaquine, and chloroquine 25 mg/kg BW for the treatment of Ethiopia , 11. UnlAccording to the third National Malaria Indicator Survey EMIS 2015), close to one-fifth of malaria cases in Ethiopia were diagnosed and treated in formal private health facilities . Among t, close tEffective malaria case management in both private and public health facilities will not only improve individual-centred care, but also prevents the transmission of diseases in the community and the emergence of ACT-resistant parasites , 17. AccIn Ethiopia, public-private partnership approaches for malaria care services have been implemented since 2012 . During The purpose of this clinical audit was to determine the adherence to standard malaria diagnosis and treatment guidelines by private health providers and compare results by partnership status among facilities located in the West Gojjam Zone of the Amhara regional state in the north-west of Ethiopia. Furthermore, the results of the study will be used to inform targeted interventions to improve the quality of outpatient malaria case management in the private health sector in Ethiopia.A facility based retrospective study design was conducted through a clinical audit  of the dwww.CSA.gov.et). Four woredas (districts), namely, Finote Selam, Jabih Tehina, Bure and Wenberma were selected based on the reported high incidence of malaria cases. In West Gojjam zone health services are provided by one hospital, 90 health centres, 363 health posts and 76 private health facilities [The West Gojjam Zone is one of the ten administrative zones of the Amhara regional state. Based on the national census  (2007), cilities . The clicilities .The target population for this study was included of adults above 18 years of age who had been beneficiaries of malaria services in the targeted 11 medium clinics in the 3 months preceding the clinical audit. Only adults diagnosed and treated for uncomplicated malaria were included in this clinical audit. Since this clinical audit was conducted to explore the clinical practice and synthesize the information to develop an in-depth interview guide for qualitative research, patients under the age of 18 years, patients diagnosed with and treated for severe and complicated malaria, and patients with two or more diagnoses were excluded from the study.woredas, the smallest administrative structures equivalent to districts, were selected based on the high burden of malaria. In 2012, the incidence of malaria in the selected four woredas ranged from 40 to over 100 per 1000 population [The West Gojjam zone was selected through purposive sampling for its accessibility from the main road and convenience for the researchers. However, the pulation . All eleThe data collection tools for the clinical audit were developed from the national and international malaria diagnosis and treatment guidelines , 8. The Yes”, “No”, or “Not applicable” as documented in the medical records. Methods of diagnosis were judged based on the findings “parasitologically confirmed using microscope”, “parasitologically confirmed using RDT” and “presumed malaria cases”. The laboratory investigation results, “P. falciparum malaria”, “P. vivax malaria” and “mixed infection ”, were extracted as documented in patient charts. Patient records with clinical and laboratory evidence of severe malaria, such as coma, severe malarial anaemia (haemoglobin or haematocrit), hypoglycaemia, circulatory collapse, renal failure (haemoglobin urea and creatinine), pulmonary oedema, spontaneous bleeding, repeated convulsions, acidosis, haemoglobinuria, impaired consciousness, jaundice, prostration, hyperpyrexia and hyperparasitaemia were excluded from the reviews for this study [The data extracted from patient medical records and outpatient facility registers were used for this study. The data elements collected include: initial or follow-up visit; patient’s age, gender and weight; temperature; chief complaints; clinical features; methods of diagnosis; diagnostic tests; parasite load; and anti-malarial drugs prescribed and administered. The diagnosis and treatment criteria adopted for the clinical audit were proofed as “is study , 10.For this study, medical records of 1650 adult outpatients who had received malaria services were audited in 11 medium private clinics. A clinical audit was systematically performed using selected information of patients who had received malaria services within the preceding 3 months (i.e. October 2016 – January 2017).2) test was employed to test for a statistically significant relationship, which was claimed at P < 0.05.Data entry and cleaning was conducted using Microsoft Excel 2010. For the statistical analysis, the cleaned data were exported to the Statistical Package for the Social Sciences (SPSS) (IBM-SPSS version 20). The descriptive results were presented using tables and graphs . For catEthical clearance was obtained from the Health Studies Higher Degrees Committee (HSHDC), College of Human Sciences (CHS), University of South Africa (UNISA). Prior to the commencement of data collection, the final version of the study protocol, together with the UNISA ethical clearance, was submitted to the Amhara Regional State Health Bureau, Research and Technology Transfer Core Process. Permission to conduct the research was obtained from the local Institution Review Board (IRB). In addition, a support letter was received from the West Gojjam zone Health Department. Consent to audit clinical records of randomly selected patients’ medical records was obtained from the heads or owners of all 11 medium clinics. To maintain the confidentiality of collected data, anonymity was maintained throughout the research process.Uncomplicated malaria is defined as “a patient who presents with symptoms of malaria and a positive parasitological test (microscopy or RDT), but with no features of severe malaria” [malaria” . Howevermalaria” .Medium clinic is the next level of health care to primary level in the health system providing ambulatory private health care that provides mainly curative, preventive and promotive services. According to the Ethiopian national minimum standards [tandards , a mediuPlasmodium spp., and parasite density would be determined as the number of parasites relative to the patient’s actual red cell count. If this is not available, an average red cell count of 5,000,000/μL of blood can be assumed in an ideal malaria diagnosis [In accordance with the National Malaria Guidelines (2012), any adult patient suspect of malaria who is seen at a health facility should be tested for malaria parasites using thick & thin blood film, stained with 10% Giemsa for 15 min. The film would then be screened under an oil immersion microscope for the presence of iagnosis , 24–26.Plasmodium lactate dehydrogenase (pLDH) specific to P. falciparum and pan specific to other Plasmodium species . A unique positive HRP2 or PfpLDH line represents a P. falciparum infection whereas a unique panpLDH line indicates an infection with one or more of the non-falciparum species. The presence of both test lines indicates either an infection with P. falciparum or a mixed infection with P. falciparum and one or more of the non-falciparum species. In cases where the control line did not appear, the results were interpreted as invalid and the test repeated with a new device is an acceptable malaria diagnosis [In the absence of a quality-assured malaria microscopy test, any adult malaria suspect patient would require testing with a malaria antigen test kit, which is a lateral flow immunochromatographic antigen detection test using finger-prick blood for rapid assay. Using this kit provides a rapid qualitative and differential test for detection of histidine rich protein-2 (HRP-2) or iagnosis , 24–26.minor error malaria diagnosis [An adult malaria suspect patient that is investigated using only Giemsa-stained thick film and has an estimated parasite density using semi quantitative + signs was categorized as iagnosis , 24–26.major error malaria diagnosis [An adult malaria suspect patient that is not identified and investigated for parasitological confirmation is considered as iagnosis , 24–26.P. falciparum and mixed  infection is treated with artemether-lumefantrine (AL) at a total dose of 5–24 mg/kg body weight (BW) of artemether and 29–144 mg/kg of lumefantrine plus a single low dose (Sld) 0.25 mg/kg BW of primaquine. Patients with P. vivax infection are treated with chloroquine phosphate 25 mg/kg BW in three divided doses [P. vivax infection is recommended only in malaria elimination targeted districts [If an adult has uncomplicated malaria then presumed malaria, ed doses . In Ethiistricts .P. falciparum or P. vivax, or a mixed infection, treated with second-line treatment recommended, AL or quinine for clinical malaria for P. falciparum, or mixed infection , and chloroquine plus primaquine for P. vivax infections, are considered as acceptable treatment [Patients with presumed malaria that have reatment .P. falciparum malaria patient, treated with either AL plus artemether injection, or to a P. vivax malaria patient, treated with chloroquine and artemether injection, or chloroquine and AL, or for both infections first-line drugs plus antibiotics prescription [minor error [This term applies to a cription . In addior error .P. falciparum or presumed malaria cases who are treated with only chloroquine and prescribed monotherapy (artemether) for P. falciparum, P. vivax, mixed or presumed cases [major error [This term applies to malaria patients with ed cases . In addior error .n = 134) of the adult patients fell into the age category range 21 to 30 years. More than half  of the outpatient malaria service beneficiaries were males. More than half (55.2%) of the adult patients were from urban areas  were dropped from analysis. The mean age with standard deviation (± SD) of the assessed adult uncomplicated malaria patients was 29.9 (± 12.2) years. Their median age was 26 years and the age range was 63 (81–18) years. A total of 40.6%  of suspected cases, malaria had been diagnosed. However, 3.69 (61/1650) medical records of severe and complicated malaria cases were excluded from further evaluation. The majority of malaria cases  had been confirmed by parasitological diagnosis, either by microscope or by malaria RDT. However, among parasitological negative patients, slightly less than one-fifth  of adults with uncomplicated malaria had been diagnosed clinically after ruling out other causes of fever. In this study, all malaria species identification and parasite load estimation were made based on thick blood films.2 (1) = 0.0). The majority  of malaria suspected patients investigated for malaria diagnosis using only thick blood film was categorized as minor error diagnosis, this performance does not reveal statistical difference by partnership status with 170/1010 in PPP, and 80/320 in NPPP; X2 (1) = 1.92, P = 0.16). Moreover, no clinical records were found without investigation which fulfil the sign and symptoms to suspect malaria which were categorized as major error in malaria diagnosis.It was found in the study that laboratory tests had been requested for all 1650 adult cases of suspected malaria. Blood tests for malaria using microscopy had been requested for the majority  of cases. On the other hand, one-fifth of cases  had been investigated using malaria RDTs that is acceptable malaria diagnosis method, this performance does not show statistical difference by partnership status of targeted facility with 176/907 in PPP; and 144/743 in NPPP, XP. falciparum, P. vivax, and mixed P. falciparum plus P. vivax infections, respectively. Looking at the 52 malaria RDT diagnosed cases, 26 (50.0%), 15 (29.0%) and 11(21.0%) had been due to P. falciparum, P. vivax, and mixed P. falciparum plus P. vivax infections, respectively . Out of 222 microscopy-diagnosed malaria cases 117 (53.0%), 67(30%) and 38(17.0%) had been due to Plasmodium vivax malaria cases had received ideal treatment as per the standard recommendation using chloroquine phosphate 25 mg/kg BW in three divided doses  malaria cases had been treated with the ideal recommendation. Accordingly, the audit revealed that only one-fifth  of adult patients who had been treated for malaria had received the ideal recommended treatment.It was found in the study that the majority  of adult uncomplicated es Table . This trP. falciparum, P. vivax or mixed infections. These prescription and practices were classified as acceptable treatment. This treatment regimen does not have significant differences  in adherence of national malaria standards by partnership status of enrolled private health facilities at X2 = 0.35; P-value = 0.55  of patients had received second-line treatment using AL or quinine or chloroquine plus primaquine for 2 = 0.12; P-value =0.72.This study showed that 13.9% (46/330) of adult patients had received AL plus an artemether injection, or chloroquine plus an artemether injection or AL, or chloroquine plus antibiotics  or AL plus chloroquine  in adherence of national malaria standards by partnership status of enrolled private health facilities at X2 = 1.16; P-value = 0.28  indicated a diagnosis of Sarkar and Seshadri  describeIn this study, the general information of patients, evidence which includes initial or follow-up visit, age, blood pressure, pulse, dark colour of urine, generalized weakness (prostration) and jaundice, creatinine, and haemoglobin or haematocrit laboratory results from investigations were used to classify malaria cases as uncomplicated or severe and complicated. These criteria are in line with national and international classification either as uncomplicated or severe and complicated malaria cases , 8, 10.In this study, history of fever 2 days prior to examination, feeling hot during examination or a measured temperature above 37.5 °C was recorded in the majority of cases of patients diagnosed with and treated for malaria. The most common clinical features like headache, chills, shivering, joint pain, backache and anaemia were checked, indicating that the high malaria investigation rate was optimal. In contrast with this finding, Meremikwu et al.  documentThe malaria parasite positivity rate was 23.7% (391/1650). This finding is slightly lower than the four-year retrospective data analysis report by Argaw et al.  of a 24.The audit documented that the majority of adults with malaria had been treated after parasitological confirmation through microscopy or RDTs, which was in line with the national and international recommendations. However, only one fifth of malaria patients had received ideal antimalarial prescriptions in line with the national and international recommendations , 8. AdheIn all 11 private health facilities enrolled in the study, relative parasite load counts were used. This semi-quantitative method of quantifying using “+” signs is recommended by WHO (1991) for use only when it is not possible to undertake a parasite count per microlitre of blood . This fiP. falciparum and P. vivax [P. falciparum, close to one-fifth (17.8%) of the malaria cases were caused by mixed  infections, while the rest (30.0%) were caused by P. vivax. This finding is in line with proportions of reported malaria species. A nationwide facility retrospective report by Argaw et al. [P. falciparum, P. vivax and mixed infection, respectively. In addition, these figures were consistent with the report of the Ethiopia malaria indicator survey (EMIS), in which P. falciparum is reported to account for 77% (MIS 2011) [P. falciparum cases only, or P. falciparum as mixed cases [In Ethiopia, the two most dominant malaria parasites are P. vivax . In thisw et al.  indicateIS 2011)  and 87.9IS 2011)  of the tthe rest 0.0% wereed cases , 37, 38.In this study, no malaria patients were investigated with ideal malaria diagnosis methods recommended by WHO . This coP. vivax malaria patients received the ideal treatment. However, not all P. falciparum, mixed and presumed malaria patients were treated based on the recommended treatment regimen of the recently revised national malaria guidelines of Ethiopia, which is AL plus SLD primaquine. Furthermore, slightly less than one-fifth of presumed malaria patients were diagnosed and received treatment after negative laboratory test results had been documented. This finding is in line with Argaw’s [Most adults were treated for a parasitologically confirmed malaria diagnosis and only 82.9%  Argaw’s  finding  Argaw’s , 40, 41.Despite these deviations from national and international recommendations, more than one third of Ethiopian mothers preferred to visit private sector facilities for their perceived responsiveness than public sector ones. This finding was in line with the Awoke et al.  report oThese major deviations from both national and international recommendations need intervention by both the private and the public sector, otherwise the poor quality of care documented in the private sector will contribute to drug resistance and loss of resources . This fiThis clinical audit was performed using retrospective data; as a result, there was a higher risk of getting incomplete and inconsistent data. In addition, it is imperative to consider the small sample size before interpreting and inferring the result of this study; the exclusion of patients age less than 18 years, diagnosed with severe and complicated malaria, and co-infected with other diseases may reduce the estimation on prevalence and species.The clinical audit revealed that the majority of malaria patients had received malaria diagnostic services with minor errors. In addition, only one fifth of malaria patients had received ‘ideal’ malaria treatment services. Therefore, efforts should be made to improve access to antimalarial supplies including absolute methanol, Primaquine and AL. In addition, enhancing the diagnosis and management capacity of healthcare providers though supervision and technical support are recommended. Finally, to understand the reasons for the low levels of malaria diagnosis and treatment adherence with national guidelines, a qualitative exploratory descriptive study is recommended.


Nephrolithiasis is a risk factor for Osteopenia and osteoporosis. Receptor activator of nuclear factor kappaB ligand (RANKL) and osteoprotegerin (OPG) regulate bone remodeling and osteoclastogenesis. This study aimed to evaluate the relation between serum OPG, RANKL concentration, and bone mineral density (BMD) in patients with kidney stone disease.Forty-four nephrolithiasis patients with either low bone mass or normal BMD (considered control group) were enrolled in this study. BMD was measured at lumbar spine (L1-L4) and femoral neck by dual-energy X-ray absorptiometry (DEXA). The serum OPG and RANKL were determined using the ELISA method.P = 0.03), respectively. Negative correlation was detected between bone densities of femoral neck and OPG in patients with nephrolithiasis .The median levels of serum OPG were significantly higher in nephrolithiasis patients with low bone mass compared to the nephrolithiasis patients with normal BMD (3.9 pmol/l versus 3.1 pmol/l; The present study showed that high serum fasting OPG levels may be indicative of femoral neck BMD in patients with nephrolithiasis. A number of studies have provided evidence for the association between kidney stone and lower BMD. In men, stronger associations have been reported between the history of nephrolitasis and low BMD , 2. In aThe aim of this study was to define the role of RANKL and OPG in the development of nephrolithiasis- related reduced bone mineral density. So we compared nephrolithiasis patients with low bone mass to nephrolithiasis patients with normal BMD to identify risk factors for the development of low bone mass in such patients.Potential participants attending the specialty clinic at Shariati university hospital, located in the city of Tehran-Iran, were invited to participate in this study. Eligible subjects with nephrolithiasis who had given written informed consent were entered into the study. All subjects had to be over the age of 18, willing and able to give written consent to the study, and had a diagnosis of nephrolithiasis. Participants were excluded if they had hyperparathyroidism, thyroid gland dysfunction, renal tubular acidosis, malignancy, longstanding corticosteroid intake. Other reasons for exclusion were use of estrogen, progesterone, bisphosphonate, calcitonin, heparins, and anti- inflammatory drugs, calcium, vitamin D and vitamin C supplements and treatment with thiazides diuretics. Information regarding nephrolithiasis in preceding years and medication use was retrieved by interviewing patients. The duration of kidney stone was considered as the difference between the current age of the subject and the age at the time of the first diagnosis of kidney stone. Ethics Committee approval was gained from Tehran University of Medical Sciences (code: EC- 00308) and all participants provided written informed consent.BMD measurement of the lumbar spine (L1-L4) and one femur was performed by dual – energy X- ray absorptiometry (DEXA) using Lunar DPX-MD device . Results were expressed as absolute values (g/cm2), Z-score and T-score. The threshold for establishing a diagnosis of Low bone mass was based on the World Health Organization definition.Samples were drawn from subjects after overnight fasting of 10–12 h at the baseline of the study. Serum fasting and plasma EDTA tubes were immediately centrifuged for 15 min at 2500×g. Serum and plasma specimens were frozen and stored at − 80 °C until assay. Serum concentrations of creatinine, BUN (Blood Urea Nitrogen), uricacid, calcium, phosphor levels were determined by a colorimetric method using Pars Azmoon kits . Serum concentration of PTH was measured by Biomenca. Serum levels of vitamin D were assayed by IDS. A 24-h urine sample was taken from subjects in order to evaluate calcium, phosphor, uric acid, citrate, createnine, and urine volume. Urine levels were measured by Pars Azmoon kits . Serum OPG and RANKL levels were measured by ELISA kit according to the indication of manufacturer ).2. Ultrasonography examinations were performed by an experienced radiologist in Shariati hospital to diagnosis kidney stone.Height (to the nearest 0.5 cm) was measured using wall mounted stadiometer. Weight was taken in minimal clothing and no shoes. BMI was calculated by dividing body weight (in kg)/ height (in m) p value of< 0.05 was considered statistically significant (SPSS Inc. USA). The variables are shown as means ±SD and median (interquartile range). The Kolmogorove Smirnov test of normality was applied. Differences between groups were tested by mann- whitnineys for none -normally distributed variables, unpaired t-test for normally distributed variables. Correlation between variables was assessed by spearman’s rank test. Receiver operator characteristic (ROC) analysis was performed to establish the discriminator performance of OPG in predicting low bone mass in patients with nephrolithiasis.A 2) BMI. Table p < 0.05).Forty four patients with nephrolithiasis (21 men and 23 women) were enrolled in this study. The majority of participants were middle age (mean age 47.5 ± 11.95 years) with a mean 28.94 ± 4.21  and − 0.7, respectively. There were significant differences in T-score of femur neck and T-score and Z-score of lumbar spine between male and female (p < 0.05). As well, higher T-score and Z-score of femur neck and higher T-score and Z-score of lumbar spine were identified in females , − 0.6 , − 0.2 , − 0.35 ) than males , − 1.2 , − 1.7 , − 1.6 ), respectively . OPG didn’t show any significant relation to lumbar spine   and kidney stone disease duration  and positively correlated with the BMI , urine phosphor  and eGFR . Femoral total BMDs were negatively correlated with age  and positively correlated with BMI , urine phosphorous  and eGFR . Lumbar spine BMDs were negatively correlated with age  and positively correlated with urine phosphor  (Table p > 0.05).There was a significant inverse linear relationship between OPG and femur neck BMDs (P = 0.03) and lower eGFR  ml/minute versus 83.96 ml/minute; p = 0.002) and higher duration of kidney stone disease  years versus 5.5 years p = 0.002) (Table p = 0.19).Patients were divided into two groups: Group 1 consisted of 23 patients with low bone mass and group 2 included 21 patients with normal BMD (control group). When comparing to control group, those with the decreased BMD were significantly found to have higher OPG levels  pmol/l versus 3.92.9,4.4) pmol/l; .4 pmol/lThere were no significant differences in age and BMI distribution. No significant differences were detected in the levels of sodium, BUN, creatinine, uric acid, calcium, phosphor, PTH, and vitamin D. As well, the differences in urine levels of citrate, phosphor, calcium, uric acid, creatinine, and volume among the two groups were not significant Table .Using a ROC analysis, our data showed that OPG levels were sensitive for the presence of low bone mass at the femoral neck among individuals with nephrolithiasis. A threshold levels for OPG at 3.38 pmol/l enabled us to detect low bone mass with AUC, sensitivity and specificity of 68% (95%CI: 52–85), 69% (95%CI: 52–82) and 67% (95%CI: 50–80), respectively.This study showed an increased circulatory OPG in nephrolithiasis patients with reduced femoral neck density. Our data showed that nephrolithiasis patients with reduced BMD have higher serum OPG levels compared to those with normal bone density. No significant association was observed between RANKL and bone densities. Among people with kidney stone, duration of nephrolithiasis is significantly and positively related to the presence of low bone mass especially at femoral neck. In addition, in ROC analysis, OPG levels predicted BMD levels at femur neck in these patients.To our knowledge, this is the first work that tries to gain some understanding on the role of serum OPG and RANKL in association with the measurements of BMD in nephrolithiasis patients. Nephrolithiasis has been demonstrated to accelerate bone loss; therefore, osteoporosis could be possibly attributed to either the presence of hypercalciuria  or decreOne explanation may be the OPG acts as a decoy substrate to RANKL and RANK competitor; thus, inhibiting the formation and activity of osteoclasts , 12. SomIn addition, we observed that femoral neck BMD was inversely correlated with serum OPG and not the vertebral spine in patients with kidney stones. Bone minerals can be divided into two types: cortical and trabecular. The femoral neck region contains both trabecular and cortical tissue whereas the vertebrae region contains high amounts of trabecular tissue –19. In tIt is well known that cortical bone turnover is increased in presence of high PTH levels . It is aThere are some limitations to our study. Although this study supported an inverse correlation between circulatory levels of OPG with BMD measurement, which highlights the potential link between nephrolithiasis and reduced bone mass, but due to the cross-sectional nature of our study cautious the causal assumption between them; whether reduced bone mass brings high levels of OPG in nephrolithiasis or that high levels of OPG in nephrolithiasis brings low bone mass. Future longitudinal studies in patients will help to determine whether the OPG provides additive predictive value for femoral neck BMD decline. In addition, A power analysis for OPG levels based on the differences demonstrated in our study between patients with low bone mass (3.14 ± 0.72) and normal BMD (3.68 ± 0.98), with an α of 0.05, resulted in a power of 58%. Thus, it is possible that our relatively small sample size limited our ability to detect true differences and an additional study with larger sample size, preferably a prospective cohort study should be pursued to confirm our findings and establish any other distinct relationships between the bone remodeling proteins in the OPG/RANKL/RANK axis and bone density in subjects with nephrolithiasis. The other limitation is that non- nephrolithiasis individual were not enrolled as controls.The present study showed that high serum fasting OPG levels may be indicative of femoral neck BMD in patients with nephrolithiasis. A deeper knowledge of mechanisms involved in the association between OPG serum levels, bone integrity, and kidney stone disease can provide more robust scientific approaching for future therapeutic interventions.


In sub-Saharan Africa (SSA), there is a significant burden of ischemic stroke (IS) and hemorrhagic stroke (HS), although data on risk factors for each type are sparse. In this systematic review we attempt to characterize the risk factors.. Results. We identified 12 studies, including 4,387 stroke patients. Pooled analysis showed that patients who had diabetes  and HIV (OR = 2.46 (95% CI: 1.59–3.81) were at a significantly greater risk of suffering from all stroke types. There were insufficient data to examine these factors by stroke type. Among case series, the pooled prevalence of hypertension was higher for HS than for IS (73.5% versus 62.8%), while diabetes mellitus (DM) and atrial fibrillation (AF) were more prevalent among IS compared to HS . We systematically reviewed ) case-control studies and case series from 1980 to 2016 that reported risk factors for IS and/or HS in SSA. For each risk factor we calculated random-effects pooled odds ratios (ORs) for case-control studies and pooled prevalence estimates for case series There remain too few data from SSA to reliably estimate the effect of various factors on the risk of IS and HS. Furthermore, the vast majority of cases were identified in hospital and so are unlikely to be representative of the totality of stroke cases in the community. Worldwide, stroke is a leading cause of death and of chronic disability . It is eStroke is a heterogeneous disease comprising subarachnoid hemorrhage, intraparenchymal hemorrhage, and IS, each of which has a very different pathophysiology . HS is tHowever, there are relatively few data from SSA that examine risk factors for stroke and in particular for HS and IS separately. Here, we systematically review the available data, thereby summarizing what is known and highlighting gaps in knowledge on a continent that is undergoing rapid epidemiological transition.Articles which were included in the review met the following inclusion criteria: (1) cohort, case-control, cross-sectional, or randomized control trial study design; (2) studies reporting risk factors for HS and IS with effect measures and 95% confidence intervals and used multivariable data analysis; (3) studies with data collected among adult patients aged 18 years and older; (4) studies conducted in SSA countries; (5) studies whose participants were clinically diagnosed with stroke as defined by the WHO criteria; (6) where stroke subtype was classified, it was by computer tomography (CT), magnetic resonance (MR), and brain imaging or necropsy; (7) articles published in English from 1980 to 2016; (8) studies from both community and hospital-based settings of first-ever as well as recurrent stroke.The exclusion criteria were as follows: (1) the original article did not have relevant information on risk factors for HS and IS; (2) duplicate report; (3) results presented only as abstracts; (4) population not living in SSA; (5) studies including children; (6) studies with unclear or no available information on risk factors in all stroke or individual stroke types or data inconsistencies. Full text/papers were sought for all studies appearing to meet the inclusion criteria based on screening of the abstract, and a final selection was made by two independent reviewers. Standardised and well described methods were used in this systematic review . Briefly(Adults OR “18 years or older”) OR Congo (DRC- Kinshasa)[Text Word] OR “Côte d'Ivoire” OR Djibouti[Text Word] OR Eritrea[Text word] OR “Equatorial Guinea” OR “Congo Brazzaville” OR Ethiopia[Text Word] OR Gabon[Text word] OR Gambia[Text word] OR Ghana[Text Word] OR Guinea[Text Word] OR Guinea-Bissau[Text word] OR “Ivory Coast”[Text Word] OR Kenya[Text Word] OR Lesotho[Text Word] OR Liberia[Text word] OR Madagascar[Text Word] OR Malawi[Text Word] OR Mauritius[Text Word] OR Mozambique[Text Word] OR Namibia[Text Word] OR Niger[Text Word] OR Nigeria[Text Word] OR Réunion[Text word] OR Rwanda[Text Word] OR “Sao Tome and Principe”[Text word] OR Senegal[Text Word] OR Seychelles[Text word] OR “Sierra Leone”[Text Word] OR Somalia[Text word] OR “South Africa”[Text Word] OR Sudan[Text word] OR Swaziland[Text Word] OR Tanzania[Text Word] OR Togo[Text Word] OR Uganda[Text Word] OR Zambia[Text Word] OR Zimbabwe[text word])#1 AND #2 AND #3 AND #4 Limits: English languageThe search strategy for PubMed: the key words which we used in our search included terms describing stroke, terms describing age, terms describing the SSA countries, and terms describing risk factors as shown in the search strategy as follows: The search yielded 617 abstracts. All abstracts were screened, and we assessed full papers of all abstracts meeting the inclusion criteria. We reviewed all relevant articles in English from 1980 to 2016. Stroke was defined as “rapidly developing clinical signs of focal, or at times, global disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than vascular origin” [An additional search was conducted in reference lists of relevant studies, journals, theses, and conference proceedings to identify publications that could have been omitted in the database searches.Two review authors  independently screened titles and abstracts of records obtained from the electronic searches and excluded those that were obviously irrelevant. We obtained the full text of the remaining studies and selected those for inclusion according to the above criteria. If any methodological question raised doubts about whether the study met the inclusion criteria, we contacted the study authors for clarification. If there was disagreement regarding the selection of studies, we attempted to reach a consensus. We recorded reasons for exclusion .Data were extracted from identified studies using a structured form by the primary reviewer (GN). A second reviewer (AK) independently checked the data extraction forms for accuracy and detail. We extracted the following information: (1) general information such as author, date of publication, and country; (2) study duration and sample size; (3) total number of participants, gender, and stroke type; (4) risk factors for stroke such as hypertension, DM, smoking, alcohol use, dyslipidaemia, HIV infection, and hypercholesterolemia. Two investigators (GN and OK) independently evaluated the methodological quality and risk of bias of eligible studies by using the Newcastle-Ottawa scale  and the I2 index. The threshold of heterogeneity was set at I2 ≥ 50%. All meta-analyses were performed with STATA version 12.0 and REVMAN. Statistical significance was set at p ≤ 0.05. To assess whether pooled prevalence and ORs for each risk factor comparison differed between HS and IS, we assessed between-group heterogeneity, using the within-group pooled estimates and their standard errors.For each risk factor, where data were available from more than one study, we performed meta-analyses. We calculated study-specific odds ratios and pooled prevalence in HS and IS patients with 95% confidence intervals (CIs) separately. We used a random-effects model for meta-analyses since there was evidence of heterogeneity . HeterogThe literature search identified 617 publications from PubMed (330), EMBASE (1), WHOLIS (61), CENTRAL (18), Google scholar (36), and Wiley online (171). Additional 6 studies were included from reference lists of relevant publications. Five hundred and sixty-two (562) studies remained after removing 61 duplicates. After screening the titles and abstracts for relevance, 532 studies were excluded  giving a total of 30 full texts that were assessed. After applying quality criteria, another 18 were excluded which did not have enough information on risk factors for hemorrhagic and ischemic stroke. A total of 12 studies were finally retained for the review. A summary of the selection process is shown in There were five case-control studies , 30–32 iSeven studies , 24–27 wAmong five case-control studies , 30–32, I2  =  68.0). One study [Four studies , 31, 32 I2  =  74.0%) in study effect size estimates. Using a random-effects model, the pooled OR was 1.26 (95% CI: 0.68–2.35). However one study [The effect of alcohol use on stroke risk was reported in four studies , 31, 32.I2  =  68.0). Using a random-effects model the pooled OR was 1.02 (95% CI: 0.59–1.79). However one study [Four studies , 31, 32 I2  =  31.0%). The pooled OR was 2.46 (95% CI: 1.59–3.81).Three studies , 30, 32 I2 = 89.0%) in study effect size estimates and random-effects pooled OR was 1.66 (95% CI: 0.78–3.55). One study [The risk of stroke with hypertension was reported in three case-control studies , 12, 32;I2 =  0.0%).Two studies , 32 asseBecause there were insufficient data from case-control studies to examine risk factors for hemorrhagic and ischemic stroke separately, we performed additional quantitative analyses using seven hospital-based descriptive studies , 24–27. There remain too few data from SSA to reliably estimate the effect of various factors on the risk of IS and HS. In this review, we identified only five case-control studies from SSA that reported information on risk factors for all stroke. Only one study reported data on IS and HS risk factors separately. Furthermore, the vast majority of cases were identified in hospital and so are unlikely to be representative of the totality of stroke cases in the community. Only 31 cases from Asiki et al. and 200 from Walker et al. were community based , 30. FurIn line with previous research, this review showed that DM is a risk factor for all stroke, but it is more prevalent among those with IS than with HS. Data from previous research has also demonstrated similar findings , 34–37. Results from our study suggest that HIV is a risk factor for all stroke, although it is more prevalent among those with IS rather than HS. A similar finding was observed in a study from Malawi . In TanzIn the limited data presented here, hypercholesterolemia, smoking, alcohol use, male gender, and hypertension were not significantly associated with stroke. The difference in the pooled prevalences for HS and IS among patients with hypertension, DM, and atrial AF was statistically significant at the 5% level. We did not have any information on the pack years in the studies we analyzed. However, according to previous research, the longer and heavier a person's smoking habit, the higher the risk of stroke . The relOur study has several potential limitations. We could not report the comparative importance of risk factors for HS and IS in SSA because of lack of published data. All included studies in this review were limited to English only from 1980 to 2016, so we may not have included all relevant studies despite our comprehensive search strategy. Other limitations pertain to the quality of the evidence provided by the included studies. Moderate to considerable heterogeneity existed among the studies included in the outcome analysis and all but two of the studies were hospital-based and may not be representative of the totality of stroke in the community. In Tanzania, only a small proportion of stroke cases  get to hThere remain too few data from SSA to reliably estimate the effect of various factors on the risk of IS and HS. Furthermore, the clear majority of cases were identified in hospital and so are unlikely to be representative of the totality of stroke cases in the community. Further work should include stroke cases identified within the context of management of predominant stroke risk factors such as diabetes and hypertension which can be improved considering the optimal drug regimens available. Interventions targeting accessibility to screening, treatment, and sociocultural aspects of health should be considered.


Autonomous ovarian activation with recurrent estrogen-producing cysts is a hallmark feature of the rare bone and endocrine disorder fibrous dysplasia/McCune-Albright syndrome. Precocious puberty in girls with McCune-Albright syndrome has been well-described, however long-term effects on gynecologic and reproductive function are unknown. Concerningly, case reports have described poor skeletal outcomes associated with pregnancy in women with fibrous dysplasia.Thirty-nine women with fibrous dysplasia/McCune-Albright syndrome were evaluated as part of a natural history study. Clinical, radiographic, and biochemical data were reviewed. Women were contacted to obtain detailed menstrual and reproductive histories.Abnormal uterine bleeding affected 77% of women (30/39), and was associated with severe anemia requiring blood transfusion in 3 cases. Nine women underwent hysterectomy for management of bleeding, including 67% (6/9) at the unusually young age of less than age 35 years. Infertility affected 43% of women (9/21), including 2 women who developed primary ovarian insufficiency after undergoing surgical treatment of ovarian cysts. Of 25 spontaneous pregnancies in 14 women, 35% (8) were unplanned. Among the 14 pregnancies, pregnancy was associated with no change in bone pain in 7 subjects (53%), increased bone pain in 4 subjects (31%), and decreased bone pain in 2 subjects (15%). No additional skeletal complications were reported during pregnancies.Women with fibrous dysplasia/McCune-Albright syndrome report a high prevalence of gynecologic morbidity and reduced fertility. There is no clear association between pregnancy and poor skeletal outcomes in this population. Disease is a rars . Girls ts , 5. GonaWhile the presentation, natural history, and clinical management of MAS-associated precocious puberty has been well-characterized, ovarian function in adulthood is poorly understood. It is unknown if women with a history of MAS-associated precocious puberty are at risk for gynecologic disease. Effects of persistent ovarian activation on fertility and childbearing, as well as the effects of pregnancy on skeletal outcomes, have not been determined. The obstetrical literature in FD/MAS is limited to case reports of skeletal complications during pregnancy, including increased FD-related bone pain , 7, aneuThe purpose of this study was to evaluate gynecologic and reproductive outcomes in a cohort of adult women with FD/MAS.Subjects were evaluated at the NIH Clinical Center between 1998 and 2015 as part of a longstanding FD/MAS natural history study. The protocol was approved by the NIDCR Institutional Review Board, and informed consent/assent was obtained from all subjects and/or their guardians. Subjects underwent history and physical exam, pelvic ultrasonography, and biochemistries to include LH, FSH, and estradiol. The diagnosis of FD/MAS was made on clinical grounds based on the presence of 2 or more characteristic features, with molecular testing as needed, according to previously published guidelines [GNAS mutation testing from FD tissue was available for 15 subjects; in 7 subjects a mutation was identified at the R201C position, and in 8 subjects a mutation was identified at the R201H position. The mean total length of follow-up was 11.5 years .Attempts were made to contact all 90 women who had been seen in the natural history protocol to obtain detailed gynecologic and reproductive histories, and responses were received from 39 subjects. Five interviews were conducted at the NIH Clinical Center, and the remainder were performed by telephone. Subject characteristics are reported in Table Pelvic ultrasounds were reviewed by a single reader (DOC). Biochemistries were drawn within 48 h of pelvic ultrasound. Biochemical assays were carried out by the Department of Laboratory Medicine at the NIH Clinical Center. From 2008 to 2015, LH and FSH were measured using Immulite  competitive immunoassay. For LH, intra-assay coefficient of variation was 3.7%, inter-assay coefficient of variation was 6.7%, and lower limit of detection was 0.1 mIU/mL. For FSH, intra-assay coefficient of variation was 3.2%, inter-assay coefficient of variation was 4.8%, and lower limit of detection was 0.1 mIU/mL. Estradiol was measured using Roche Cobas e601 analyzer  electrochemiluminescence immunoassay. Intra-assay coefficient of variation was 1.9%, inter-assay coefficient of variation was 3.1%, and lower limit of detection was 4 pg/mL. For assays run prior to 2008, LH and FSH were measured using a Microparticle Enzyme Immunoassay . For FSH, intra-assay coefficient of variation was 4%, inter-assay coefficient of variation was 3%, and lower limit of detection was 0.37 mIU/mL. For LH, intra-assay coefficient of variation was 5%, inter-assay coefficient of variation was 4%, and lower limit of detection was 0.5 mIU/mL. Estradiol was measured using Immulite  competitive immunoassay. Intra-assay coefficient of variation was 6.6%, and lower limit of detection was 15 pg/mL. In pre-menopausal women, levels vary widely according to menstrual cycle, but are typically in the range of 15–350 pg/mL for estradiol, 1–24 U/L for FSH, and 1–100 U/L for LH.Statistical tests were performed using GraphPad Prism 7.03 . Comparisons between groups were performed using t-tests and Mann-Whitney tests, depending on the normality of the distribution. Results are reported using mean (standard deviation) or median (inter-quartile range)(IQR) as described, depending on the normality of the distribution.Chronic abnormal uterine bleeding was defined as vaginal bleeding that is abnormal in regularity, volume, frequency, or duration, and has been present for the majority of at least 6 months , 13. Mosn = 2, both effective), and combination estrogen/progestin patch .The most common treatment for abnormal uterine bleeding was oral contraceptive pills . This was reported to be effective in most subjects . Other treatments included levonorgestral intrauterine devices  were performed in women at the unusually young age of < 35 years.Fertility was assessed in the subset of women who had either achieved pregnancy, or reported ≥12 months of unprotected intercourse between ages 15 and 44. Out of 21 women in whom fertility status could be evaluated, 9 (43%) met criteria for infertility. This included 7 women who failed to achieve spontaneous pregnancy after 12 months of unprotected intercourse, and 2 women who carried a medical diagnosis of primary ovarian insufficiency. 8/9 women who met criteria for infertility (89%) had a history of MAS-associated precocious puberty.One woman was diagnosed with primary ovarian insufficiency after presenting with secondary amenorrhea at age 16. Lab work at that time showed FSH 60 U/L, LH 40 U/L, and undetectable estradiol. She had a history of precocious puberty presenting at age 7 months, and underwent bilateral cystectomy at age 23 months. She continued to have symptoms of precocious puberty, and was treated with testolactone from ages 3 to 8. After discontinuing testolactone she had irregular menses until her presentation with secondary amenorrhea at age 16.Another woman also presented with secondary amenorrhea at age 16 years, with a biochemical evaluation that showed FSH 61 U/L, LH 29 U/L, and undetectable estradiol. She had a history of precocious puberty presenting at age 6 months, at which time she developed by a large cyst complicated by ovarian torsion. She underwent unilateral salpingo-oophorectomy, and following surgery had no additional symptoms of precocious puberty, began spontaneous breast development starting at age 10, and regular menses starting at age 11. Neither woman reported environmental exposures or medications associated with ovarian toxicity. No autoimmunity or additional disorders associated with ovarian insufficiency were identified in either subject.A total of 25 pregnancies occurred in 14 women. All pregnancies were spontaneous, without the use of assisted reproductive technology, and 8 (35%) were unplanned. Four pregnancies (18%) resulted in spontaneous abortion, and 6 (27%) resulted in therapeutic abortion. One pregnancy (4%) resulted in fetal demise due to placental abruption at 27 weeks gestation. A total of 14 live births occurred from 10 women. Thirteen of these births were full-term, and 1 was pre-term at 36 weeks gestation. Eight live infants were delivered vaginally (54%), and 6 were delivered by Caesarian section (46%). The indication for Caesarian section was described as fibrous dysplasia-related in 4 deliveries, and fetal status-related in 2 deliveries.Menses were associated with no change in bone pain in 22 subjects (56%), increased bone pain in 12 subjects (31%), decreased bone pain in 0 subjects, with 5 subjects unsure. Among the 14 pregnancies, pregnancy was associated with no change in bone pain in 7 subjects (53%), increased bone pain in 4 subjects (31%), decreased bone pain in 2 subjects (15%), with 1 subject unsure. The postpartum period was associated with no change in bone pain in 10 subjects (71%), increased bone pain in 1 subject (7%), and decreased bone pain in 3 subjects (21%).No additional skeletal complications, including aneurysmal bone cysts or malignant transformation, were reported during pregnancy.p = 0.11). The median LH levels for subjects with and without ovarian cysts was 1.1 U/L  and 2.6 U/L , respectively (p = 0.17). The corresponding median FSH levels were 1.1 U/L  and 2.5 U/L , respectively (p = 0.46).Of the 39 total subjects, 19 had premenopausal radiographic and biochemical data available for review. Results of simultaneously obtained gonadotropins, estradiol levels, and pelvic ultrasonography are shown in Table Findings from this large series demonstrate that autonomous ovarian activation in MAS persists into adulthood, with significant effects on gynecologic function and reproduction. In our cohort, abnormal uterine bleeding resulted in significant morbidity, including the need for blood transfusions in multiple subjects. This is consistent with previous case reports and small series reporting menometrorrhagia –17. TreaOvarian cysts persisted into adulthood in this cohort, resulting in hyperestrogenism and suppression of pituitary gonadotropin production in some patients. Implications of hyperestrogenism in women with MAS are unclear. MAS has recently been associated with an increased risk of breast cancer, particularly in younger women . PrecociThis is the largest series to report data on fertility in women with MAS. Previous reports have been limited to single cases and small series, which have reported both spontaneous pregnancies , 21–24 aIf anovulation is the primary cause of infertility in MAS, ovarian cyst frequency may predict an individual’s degree of fertility impairment. There are 4 reports of women with frequent ovarian activation who underwent unilateral oophorectomy in attempts to improve contralateral ovarian function and fertility , 25, 26.The effects of menstruation and pregnancy on FD has been an area of much speculation and concern for patients. Case reports have described aneurysmal bone cysts and malignant transformation in pregnant women, fueling conjecture that pregnancy hormones may affect adversely affect the metabolic activity of FD lesions –11. OsadStrengths of this study include the large number of subjects and extensive follow-up. This is the first cohort study to establish gynecologic disease as a highly prevalent source of morbidity in MAS, to evaluate fertility and reproductive outcomes in women with MAS, and to report on skeletal outcomes in pregnancy. This is also the first report of primary ovarian insufficiency as a potential consequence of pelvic surgery in MAS, a novel finding that may directly inform gynecologic management. Limitations include the retrospective nature of the study design. Clinical outcomes data were not collected at same time as radiographic data and biochemical data, and are subjected to recall bias. Interpretation of ultrasound and biochemical data is limited, because studies were obtained in a cross-sectional manner and were not standardized according to menstrual cycles. Additional, prospective studies are needed to characterize the prevalence and frequency of ovarian cysts, which will provide important context for these clinical findings. Prospective studies should correlate gynecologic data with skeletal outcomes and surrogate endpoints, such as bone turnover markers, to more fully investigate the effects of these hormonal changes on mineral metabolism. Selection bias likely resulted in over-representation of more severely affected patients among respondents. The high prevalence of precocious puberty among respondents likely reflects this selection bias. This data should therefore be generalized only to patients with known MAS ovarian involvement.Abnormal uterine bleeding is common in MAS and may result in significant morbidity, including severe anemia and hysterectomies at an early age. In this series, the prevalence of infertility was substantially increased over the national average, however the prevalence of unplanned pregnancies was only mildly reduced. Menses and pregnancy were not consistently associated with increased FD-related bone pain or skeletal complications. These findings will inform family planning for patients with FD/MAS by highlighting both the potential for spontaneous pregnancy, as well as possibility of impaired fertility and need for reproductive assistance.


Moreover, it was evident that the protein isolates were completely digested. The biologically active potential of the digests was evaluated measuring in vitro antioxidant capacity by three complementary methods and enzyme inhibitory effects towards Angiotensin-I Converting Enzyme (ACE) related with the onset of hypertension. All hydrolysates act as a DPPH and ABTS scavenger, as a reducing agents and an ACE enzyme inhibitor. In conclusion, protein isolates obtained from apricot kernel cake showed to be a promising source of natural products for food applications, with good functional and bioactive properties and easy digestibility.The study describes and compares bio-functional properties and thein vitrodigestibility of protein isolates from apricot oil cakes obtained by supercritical fluid extraction and cold pressing, as control. Protein isolates have the potential to be food ingredients with amygdalin contents in an amount considerably lower than regulatory. Isolates showed hypoglycemic activity, studied by the inhibition of  Prunusarmeniaca L.) continually increases with demands from the fruit and food industry. In 2016 world apricot production amounted to 3.8 million tonnes [Prunus species . Generally, fruit kernels are valuable sources of oils that are rich in functional bioactive compounds such as essential fatty acids, tocochromanols, carotenoids, phytosterols and squalene. Several methods have been utilized worldwide to extract the oil from fruit kernels such as screw pressing, direct solvent extraction or pre-pressing followed by solvent extraction. These conventional methods have got a number of disadvantages: environmental pollution, high energy consumption, time-consuming, cost, requirement of organic solvent, and intensive separation technology.The global production of apricot  . The goa2 is the most preferred supercritical solvent due to a number of its advantages in food extractions, such as low critical temperature (31 °C), no toxicity, non-explosive nature, and low price [SFE has been widely used since it enables the recovery of valuable food ingredients from natural matrices with high yield and the production of better quality products with improved functional and/or nutritional characteristics by operating under a wide range of conditions . CO2 is 2 also generated by-products  where some of them could have a high protein content that have not been reused and characterized. Therefore, apricot kernel oil cake could constitute cheap source of proteins. Moreover, this is supported by the fact that essential amino acids in apricot kernel constituted 32–34% of the total amino acids, and major ones are arginine and leucine with 21.7–30.5 and 16.2–21.6 mmoL/100g meal, respectively [However, oil extraction by supercritical COMany authors have evaluated the potential of fruit seeds for production of bioactive peptides from isolated proteins . GeneralThere has been a constant search for unconventional new protein sources for use as functional food ingredients and at the same time for nutritional supplements. To our knowledge, there has not been study on valorisation of by-products obtained after SFE into valuable protein product with potential bioactive and functional properties. Hence, this study proposes to evaluate the potential of apricot kernel oil cake for production of protein isolate whit good bio-functional properties, such as solubility, water and oil adsorption capacity, foaming and emulsifying ability and potential hypoglycaemic activity. Moreover, digestibility and ability for realising of bioactive hydrolysates with antioxidant and ACE inhibitory activity will be assayed.2 extraction (SFE) . Angiotensin-I Converting Enzyme (ACE) from rabbit lung, N-Hippuryl-His-Leu (HHL) hydrate, 2,2′-azino-bis (3-ethylbenzothiazoline-6-sulphonic acid) (ABTS), 2,2-diphenyl-1-pikryl-hydrazyl (DPPH) and pancreatin from porcine pancreas, with declared activity of 4 × USP specifications of units  units/mg), Amigdalin (≥99%) standard, α-glucosidase from Saccharomyces cerevisiae with declared activity of 107 U/mg, 4-Nitrophenyl α-D- glucopyranoside were obtained from Sigma . Pepsin from porcine stomach was purchased from AppliChem , with declared activity of min 0.7 FIP U/mg. and min 1500 U/mg, respectively. All the other chemicals used for the experiments were of analytical or better grade. Proximate analysis was conducted using standard Association of Official Analytical Chemists (AOAC) (1990) methods.The apricot kernels were obtained from Association of fruit brandy producers . Oil cakes obtained by cold pressed (CP) and supercritical CO3HCl. After centrifugation  and supercritical fluid extraction (PISFE) was performed by alkali extraction with isoelectric precipitation. The apricot cakes, which were defatted with hexane in ratio 1:5, were suspended in water solution at alkali pH 10.00 in ratio 1:10. After 30 min of extraction the slurry was filtered to remove the insoluble material. The filtrate that contain the dissolved proteins were precipitated by setting pH to 5.00 with 1 moL/dmThe solubility of protein isolate (PI) was determined at pH range 2.0–9.0 and ionic strength range 0.1–1.0 moL/L NaCl. 10 mg of PI was weighted into Eppendorf tubes and added to 1 mL of a propriety buffer solution. The prepared samples were constantly stirred for 1 h at 25 °C, using a Thermo-Shaker TS-100C . Soluble proteins from supernatant were determined by the Lowry et al.  method.(water or oil)/g PI.Method described by Rodsamran and Sothornvit , with so0) and 60 min (V1). The FC and FS were expressed, in percent, as the V0 and V1 divided by the total volume (× 100).The foaming capacity (FC) and foaming stability (FS) were determined using a modified method described by Rodsamran and Sothornvit . A half E is volume of the emulsion.Emulsions of PIs were prepared and characterized according to method described by Bučko et al. .Sunflowev/v).Method was made according to Bolarinwaa et al. , with soAssay for this method was described by Chan et al .3) was pre-incubated at 37 °C, then adjusted to pH 2.5 and added pepsin. After 120 min gastric digestion, pH of the solution was adjusted to pH 7.00 and added pancreatin and intestinal digestion was carried out next 120 min. After 120 min the reaction mixture was heated at 100 °C for 5 min and centrifuged using Sorvall®RC—5B Refrigerated Super Speed Centrifuge  at G-force 9220 and 4 °C for 10 min. The collected supernatants were further analysed.PIs were hydrolysed using gastrointestinal proteases in order to simulate the human gastrointestinal environment. Digestion was performed in a glass reactor using a combination of two enzymes, pepsin (E/S 1/25) and pancreatin (E/S 1/50), at 37 °C during 4 h. Briefly, the PI suspension in water (2.5 g/100 cmThe degree of the hydrolysis (DH) was set by method described by Popović et al. .Accordinw/v) acrylamide stacking gel and a 10% (w/v) acrylamide separation gel.Proteins and hydrolysates were separated using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), described by the method of Laemmli . System blank is the absorbance of the blank solution, Asample is the absorbance of the sample solution.The assays were carried out according to the method by Morales and Jiménez-Pérez  with somcontrol is the concentration of ABTSin blank (in the presence of buffer instead of protein extract) and Asample is the concentration of ABTSin the sample (in the presence of protein extract), after 10 min of reaction.The assay as described by , ABTS scFor determination of the reducing power it was used a method . The samv/v) TFA (trifluoroacetic acid) in double-distilled water. Inhibition of ACE was calculated by equation:blank is the peak area without ACE inhibition and HAsample is the peak area in the sample.The ACE- inhibitory activity of the hydrolysates was measured following the method described by Yoshi-Stark, Bez, Wada&Wäsche . Method p < 0.05). Differences between the treatment means were separated using Duncan’s multiple range tests.The data were in triplicate, and subjected to statistical analysis, using analysis of variance (ANOVA) to determine significant differences between the samples (The apricot stones generally contain a seed with a high content of proteins and lipids. According some authors apricot kernel contained 28% protein and 52% oil . ProximaNevertheless, one limitation to the exploitation of this sustainable source for protein and oil production is the presence of cyanogenic glycosides such as amygdalin. The hydrolysis of amygdalin results in benzaldehyde, with a typical bitter taste, and cyanide. The European Food Safety Authority establishes a maximum level of cyanide of 50 mg/kg in nougat, marzipan or their substitutes or similar products, 5 mg/kg in canned stoned fruits, and 35 mg/kg in alcoholic beverages. Amygdaline was detected in PICP in amount considerably lower than those in the regulative, while in PISFE amygdaline did not detect . SimilarThe functional properties influence the behaviour of proteins in food systems during processing, storage, preparation and consumption. Solubility is one of the most important characteristics of proteins because it directly affects the other functional properties. The protein solubility profiles of PICP and PISFE in different pH, and ionic strength are shown in WAC and OAC influence the texture and mouthfeel characteristics of foods and food products. The WAC and OAC significantly differed among two PIs, their values were reported in EC was measured in this work as oil droplet size since smaller droplets reflect high emulsifying ability of a protein. The mean droplet diameter of the emulsions is presented in 50 value of 343.58 mg/mL which was in a range with a reported IC50 values for some other protein compounds [Diabetes mellitus characterized by hyperglycemia is important health issues worldwide. Diabetes mellitus is spreading very rapidly while currently available drugs, acarbose and miglitol, possess many gastrointestinal side effects on diabetics. α-Glucosidase inhibitors is an effective approach for controlling the postprandial and fasting blood glucose levels. Generally, there is a huge interest for efficacious α-glucosidase inhibitors with low side effects. Several plants and their extracts have been evaluated for their potential role against α-glucosidase enzyme. Besides phenolic components, proteins and their hydrolysates have also attracted attentions. The α-glucosidase inhibition of PICP and PISFE are shown in ompounds .DH was parameter for monitoring the protein hydrolysis. During simulated digestion, the hydrolysis rates of both investigated PIs followed a same trend, The protein profiles of native and digested PICP and PISFE were observed by SDS-PAGE, All of these, above mentioned, show that apricot cakes protein could be easily digested. According to the Codex Alimentarius Commission-2003 approach it is recommended for the assessment of potential allergenicity of novel proteins to include an in vitro pepsin digestion assay. The digestibility of novel proteins in simulated gastric fluid is considered to be an indicator of reduced risk of allergenic potential in food.The antioxidant capacity of a food or biological sample depends of many factors; hence it is advisable to use more than one assay for its determinations. Antioxidant capacity observed after both in vitro digestion steps for both PIs in every assay are presented in 50 were 78 µg/mL for PICP and 71 µg/mL for PISFE after pepsin digestion step, but they are increase after pancreatin digestion to values of 141 µg/mL for PICP and 92 µg/mL for PISFE (50 value after simulated gastrointestinal digestion was about 150 µg/mL [ACE inhibitory peptides from diverse protein sources have been extensively studied including cereal, oilseeds, milk, and macroalgae . Both PIor PISFE . These rApricot oil cakes, obtained after both oil extraction process, cold pressing and supercritical fluid extraction contain significant amount of proteins which can be prepared by alkaline extraction followed by isoelectric precipitation method. The protein isolate possesses good functional properties and potential hypoglycemic activity. Moreover, these proteins are easily digestible. The present study will provide better knowledge about the degradation of apricot kernel protein isolate in the digestive system that would be relevant for the development of easily digestible products for human food applications. The promising bioactivity of protein hydrolysates obtained by digesting suggests their potential use as a novel nutraceutical ingredient.


Some studies have demonstrated that concurrent chemo-radiotherapy is an effective salvage treatment for isolated para-aortic lymph node (PALN) recurrence.However, no studies have compared multi-treatment modalities, such as radiation therapy (RT), concurrent chemoradiotherapy (CCRT), surgery, chemotherapy, and best supportive care (BSC), across a sufficient number of patients with PALN recurrence. We thus aimed to evaluate the clinical outcomes of multi-treatment modalities for isolated PALN recurrence in uterine cervical cancer.Records of 50 patients who were first diagnosed with isolated PALN recurrence after definitive cervical cancer treatment from 2002 to 2016 at our institution were reviewed retrospectively. The initial definitive cervical cancer therapies included RT alone, CCRT, or surgery with or without post-operative RT. The median follow-up time was 33 months. The median age at recurrence diagnosis was 57 years . The median duration between the end of initial treatment and recurrence was 10 months . The median maximum metastatic lesion size was 17 mm . Twenty-four patients had one or two PALN metastases, while 26 had 3 or more. Eighteen patients were treated for recurrence with RT alone, seven with CCRT, three with surgery, 17 with chemotherapy, and five with BSC. Potential prognostic factors included histopathology, initial FIGO stage, initial treatment, age at recurrence, tumor markers (serum SCC-Ag and CEA) at recurrence, time to recurrence, maximum size of the metastatic lesion, number of metastases, and the recurrence treatment method.p = 0.014). Univariate analysis revealed that only the recurrence treatment method was significantly associated with OS. The 3-year local control rate (LCR) and progression free survival (PFS) rate for CCRT were 100 and 71.4%; for surgery, 100 and 66.7%; for chemotherapy, 33.6 and 13.7%; and for RT, 55.5 and 14.1%, respectively . The number of metastatic lesions, SCC-Ag levels and recurrence treatment method were significantly associated with LCR. Age at recurrence, SCC-Ag levels, and number of metastatic lesions were significantly associated with PFS.The 3-year overall survival (OS) rates of all patients were 47.0%. The 3-year OS rate of patients who underwent CCRT for recurrence was 85.7%; surgery, 66.7%; chemotherapy, 48.8%; RT, 41.3%; and BSC, 0% (Although our patient cohort size was small, our results suggest that CCRT may be effective in preventing local disease recurrence in the PALN and may improve OS. Uterine cervical cancer is one of the most common gynecologic cancers in Japan and has been associated with an excellent tumor control rate and favorable prognosis after definitive radiotherapy (RT), radical hysterectomy with pelvic lymph node dissection for early stages, and chemo-radiation therapy (CCRT) for locally advanced stages. However, approximately one-third of patients who are treated for cervical cancer develop recurrence , 2. The However, no studies have compared multi-treatment modalities, such as radiation therapy (RT), concurrent chemoradiotherapy (CCRT), surgery, chemotherapy, and best supportive care (BSC), across a sufficient number of patients with PALN recurrences. The aim of this study was to evaluate the outcome of patients with isolated PALN recurrence after definitive treatment for primary cervical cancer at our institution.This study retrospectively examined the data of 50 patients who were first diagnosed with isolated PALN metastases after definitive cervical cancer treatment, from 2002 to 2016, at our institution. Initial definitive treatments were performed with RT alone, CCRT, or surgery with or without post-operative RT (PORT). The median follow-up time was 33 months, and the baseline patient characteristics are summarized in Table Patients who had any evidence of metastatic disease in addition to PALN recurrence were excluded from this analysis.The Institutional Review Board (IRB) of our institution approved this study (R-514).The median follow-up time was 33 months, and the baseline patient characteristics are summarized in Table 2 or weekly nedaplatin 30 mg/m2.RT was performed with 10-MV photons using linear accelerators. A three-dimensional treatment-planning system was used for all patients, and all patients underwent four fields of irradiation. The RT target volume was the regional PALN area followed by PALN metastases, except in one patient in whom the target volume was the regional pelvic and PALN areas. For the RT field of prophylactic PALN irradiation, the superior margin was at the T12-L1 intervertebral space, and the inferior margin was located between the L4 and L5 intervertebral space or matched to the superior edge of the previous pelvic port. In boost irradiation for PALN metastases, the 5-mm margin to PALN metastases was added to the clinical target volume (CTV). A 5-mm setup margin for clinical target volume (CTV) was added to the planned target volume (PTV). Irradiation fields were obtained by providing a 5 mm leaf margin for the PTV. Doses were prescribed to the isocenter of each field. The median dose for the regional PALN area was 44 Gy . The median dose for PALN metastases was 55 Gy (range: 50–58 Gy). All patients were treated using 2.0 Gy per fraction or 1.8 Gy per fraction. Concurrent chemotherapy was performed with weekly cisplatin 40 mg/mOf the 17 patients who received chemotherapy, the chemotherapy regimens were paclitaxel/carboplatin in seven, docetaxel/carboplatin in four, irinotecan/cisplatin in three, irinotecan/nedaplatin in one, paclitaxel alone in one, and docetaxel alone in one.Of the three patients who received surgery, para-aortic lymph node dissections were performed in two, and metastatic lymph node resection was performed in one. There was no operative mortality. Postoperative chemotherapy was performed in two patients, with paclitaxel/carboplatin in one and irinotecan in the other.Prognostic factors were evaluated for their impact on overall survival (OS), local control rate (LCR), and progression-free survival (PFS). Potential prognostic factors included histopathology, initial FIGO stage, initial treatment, age at recurrence, tumor markers (serum SCC-Ag and CEA) at recurrence, time to recurrence, maximum size of the metastatic lesion, number of metastases, and the recurrence treatment method.Toxicities were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. In the RT alone and CCRT arms, acute toxicity was defined as toxicity that occurred within 90 days after completion of radiation therapy, and any toxicity that occurred more than 90 days after treatment was regarded as late toxicity.Physical examination, laboratory tests to evaluate serum tumor markers, SCC and/or CEA, chest-abdominal CT scans, and FDG-PET scans were used for the follow-up analysis. After completion of the treatment, patients were reviewed within 4–6 weeks, then every 3 months in the first 2 years, and every 4 months thereafter. Patients were evaluated with CT scans 1 month after treatment completion, and every 3–6 months thereafter. During follow-up, if the tumor marker levels elevated or if examination findings suggested possible recurrence, we performed CT scans or FDG-PET scans earlier than planned.p-values of 0.05 or less, based on two-sided tests. Missing data were excluded from the analysis.The database was analyzed using a software program . OS, LCR, and PFS were evaluated using the Kaplan Meier method, and prognostic factors were evaluated using the log-rank test. Survival time and LCR were calculated from the diagnosis of PALN recurrence until death or a censored date. Statistical significance was defined as p = 0.014)  , serum SCC-Ag level (p = 0.012), and recurrence treatment method were significantly associated with LCR  , serum SCC-Ag (p = 0.002), and number of metastatic lesions (p = 0.009) were significantly associated with PFS  and genitourinary (GU) toxicities occurred in any group. Grade 3 late GU toxicity  occurred only in one patient, who had received CCRT. The ureteral stricture formed in both the initial and boost radiation fields. Hydronephrosis due to urethral stricture was treated using a urethral stent. In chemotherapy, surgery, and RT alone groups, no grade 3–5 GI and GU late toxicities were observed. There were no hematological grade 3/4 toxicities.A total of 15 patients experienced disease progression at 19 sites after RT or CCRT. Most of the failures (8/19) occurred in the supraclavicular or mediastinal lymph nodes. Two patients had recurrences in the pelvis, five patients had recurrences in PALNs, and four patients had other distant metastases. Among the patients with PALN recurrences, two patients had local recurrences and three patients had regional recurrences.Salvage treatment modalities for isolated PALN recurrences after primary definitive cervical cancer treatment are equivocal. In the current study, we retrospectively examined a population of 50 patients with isolated PALN recurrence of cervical cancer. Our patient sample size was substantially larger than that of prior studies, and this is the first report to show the superiority of CCRT over other treatment modalities. Concurrent para-aortic irradiation and cisplatin-based chemotherapy generates an excellent prognosis, with a 3-year OS rate of 85.7%, 3-year LCR of 100%, and 3-year PFS of 71.4%. Previously, it has been suggested that RT confers long survival. Niibe et al. [n = 7), in which radiation doses ranged from 45 to 50.4 Gy. Chou et al. [n = 9), supraclavicular lymph node (n = 10), and inguinal lymph node (n = 3) recurrences. Patients who had both a long no-evidence-of-disease period and CCRT showed a 72.9% 5-year PFS rate and a 60% 5-year OS rate. In this study, concurrent chemotherapy was identified as an important factor for achieving a good prognosis. Radiation was delivered to PALN regions, up to 41.4–50.4 Gy, and then a radiation boost was administered to PALN recurrences, up to a total dose of 60 Gy. In our study, we found that patients who were treated with CCRT had better survival outcomes compared to those treated with other modalities. In patients treated with RT, RT was performed for the regional PALN area, up to a median dose of 44 Gy, followed by for the PALN metastases, up to a total median dose of 55 Gy. Regarding the total dose that should be administered to patients, considering results from previous studies [The reports from Singh et al. , Chou etu et al.  examinedu et al.  examined studies  and the p = 0.012) and PFS (p = 0.002). Jeon et al. [With respect to the prognostic factors, serum SCC-Ag levels were significantly associated with LCR  may provide a much higher radiation dose to the tumor with a steep dose gradient and reduce the radiation dose to normal tissues. Choi et al.  reportedAlthough the number of the patients was small in the current study, surgery also showed promise as a treatment, with an OS rate of 66.7% and LCR of 100%. Although surgical treatment is not widely accepted for patients such as ours, surgery has been reported to be feasible for PALN recurrences in colorectal cancer , 12. Forp = 0.036), local control (p = 0.006) and progression free survival (p = 0.007).On the basis of the reported results, multidisciplinary management might be a promising treatment for isolated PALN recurrences. If we consider the outcomes reported for the patients undergoing surgery as well as another treatment (most of them underwent adjuvant chemotherapy) and the outcomes for CCRT, there was a higher 3-year survival rate and better local control in the former group, while RT alone and chemotherapy alone was associated with a lower rate of survival (The study has some limitations. First, because this study was retrospective and performed at a single institution, careful consideration for possible selection bias is important. Clinical decisions for recurrent PALN treatment were frequently made based on time to recurrence after initial therapy completion, the location, number, and size of the metastatic lesions. For patients with a time to recurrence of less than 6 months and those with recurrence at the margin of the field of initial therapy, we often chose chemotherapy, rather than RT alone or CCRT. For patients with multiple and relatively larger metastatic lesions, we often chose CCRT, rather than RT alone. However, there were no significant differences between the treatment groups in terms of the assessed variables, except age at recurrence. Second, this study involved a relatively small number of patients. The clinical experience of fifty patients is insufficient to conclude that CCRT is superior to the other treatment modalities. However, isolated PALN recurrence is an infrequent occurrence after pelvic definitive therapy, and past studies have included a smaller number of patients. In the management of a relatively rare but curable oligo-recurrence, it is important to suggest this promising treatment strategy. Finally, the diagnoses of recurrent PALN were not histopathologically proven.In conclusion, although the patient cohort was small and there was selection bias, our results suggest that CCRT may effectively prevent local progression of disease recurrence in association with PALN and improve PFS and OS. Negative SCC-Ag and a small number of metastases may be one of the indicators of curable disease, and such patients may be candidates for salvage CCRT.Additional file 1: Table S1. Patient characteristics of each treatment group.