Intrathecal meperidine also effectively reduced need for intraoperative rescue analgesics  and the incidence of pruritus was unaffected . However, nausea and vomiting increased . Under TSA, these results provided a sufficient level of evidence. In conclusion, adjuvant low dose intrathecal meperidine effectively attenuates spinal anaesthesia-associated shivering and reduces rescue analgesics with residual concerns for the nausea and vomiting.The aim of this systematic review and meta-analysis is to evaluate the pros and cons of adjuvant low dose intrathecal meperidine for spinal anaesthesia. We searched electronic databases for randomized controlled trials using trial sequential analysis (TSA) to evaluate the incidence of reduced rescue analgesics, shivering, pruritus, nausea and vomiting when applying adjuvant intrathecal meperidine. Twenty-eight trials with 2216 patients were included. Adjuvant intrathecal meperidine, 0.05–0.5 mg kg Shivering generates heat to maintain body temperature, but it induces stress responses, interferes with surgical procedure and anaesthesia monitoring, and causes postoperative pain and discomfort8. In addition, perioperative shivering causes lactic acidosis, increases blood, intraocular and intracranial pressure as well as metabolic demand and oxygen consumption12.Occurring in about half of patients receving spinal anaesthesia, shivering15. With dosage of 0.5–1.0 mg kg−1 intrathecally for spinal anaesthesia, meperidine provided adequate sensory blockage and postoperative analgesia18. However, drowsiness and pruritus might occur along with nausea, vomiting and even respiratory depression at such a high dose intrathecal meperidine22. Due to the above adverse effects, combining local anaesthetics with relatively lower dosage, 0.05–0.5 mg kg−1 intrathecal meperidine, were suggested to provide adequate analgesia with less side effects24.Meperidine is an intermediate lipid soluble opioid with potent local anaesthetic properties1. Controversies exist about the dose-dependent anti-shivering effect27. Intrathecal meperidine, dosage as low as 0.2 mg kg−1 or 12.5 mg, was reported to show an anti-shivering effect without nausea and vomiting, but other studies did not show similar effects32. Controversy remains about intrathecal local anaesthetics combined with lower dose meperidine causing adverse effects such as bradycardia, hypotension, pruritus, nausea and vomiting33. Therefore, this systematic review and meta-analysis with trial sequential analysis focuses on whether low dose, 0.05–0.5 mg kg−1, intrathecal meperidine adjuvant with local anaesthetics could prevent shivering without significant side effects during spinal anaesthsia.Although intrathecal meperidine was suggested for both analgesia and shivering prevention in spinal anaesthesia, comprehensive evidence for and against this is lacking34. Review protocol has been registered in PROSPERO  before the study.This study was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines−1 up to 25 mg, adjuvant intrathecal meperidine in patients receiving spinal anaesthesia and noting outcomes of interest (incidence of shivering or drug-related adverse effects). We excluded: 1) interventions delivered through oral, parenteral or epidural routes; 2) different regimens or doses of local anaesthetics given between the experiment and the control; 3) meperidine given alone without local anaesthetics; 4) non-elective surgery; and 5) duplicate reporting of patient cohorts.In duplicate and independently, two reviewers (Y.C.L. and C.Y.C.) screened all articles and abstracts as randomized controlled trials (RCTs) evaluating the effects of low dose, 0.05–0.5 mg kghttp://clinicaltrials.gov/). The relevant keywords used for medical subject headings and free text searches were meperidine, pethidine, demerol, meperidine hydrochloride, spinal anaesthesia, neuraxial anaesthesia, intrathecal anaesthesia, regional anaesthesia, subarachnoid anaesthesia, lumbar anaesthesia, shivering, postoperative shivering, post-anaesthetic shivering, spinal-induced shivering, chills, and chillness. Related citations were used in the PubMed search with no language restrictions through April 2017.Y.C.L. and C.Y.C. performed a comprehensive literature search independently in databases including PubMed, EMBASE, the Cochrane Library databases, Google Scholar and the ClinicalTrials.gov registry (35.Two reviewers (Y.C.L. and C.Y.C.) extracted the baseline as well as all outcome data, including the study design, the participant data, the inclusion and exclusion criteria, the type of surgery, temperature control, spinal anaesthetic techniques and drugs adopted, and any resulting complications. If an agreement could not be reached, the dispute was resolved with the help of a third reviewer (C.C.C.). To overcome unit-of-analysis error, we combined groups to create a single pair-wise comparison for the final analysis, and divided the “shared” group equally in subgroup analyses in comparing different regimen of low dose groups, as the Cochrane handbook recommended36. Disagreements about subtracted data were adjudicated by a third reviewer (C.C.C.).We assessed the quality of each study based on the adequacy of randomization, the allocation concealment, the blinding of the patients and the outcome assessors, the length of the follow-up period, the reporting of study withdrawals, the performance of an intention-to-treat analysis, and other potential bias assessed by Cochrane Collaboration’s toolhttp://www.ctu.dk/tsa/)37, SAS 9.4  software for meta-regression, and Comprehensive Meta Analysis Version 2  for publication bias. A random-effects model was used to calculate the pooled estimates of adjusted relative risk (RR). Standard deviations were estimated from the confidence interval (CI) limit, and the standard error or range values were provided from studies cited. The effect sizes of dichotomous outcomes were reported as RR and the precision value based on a 95% CI. A pooled estimate of value was calculated using the DerSimonian and Laird random-effects model38.The primary outcome was the incidence and intensity of shivering after receiving spinal anaesthesia. The secondary outcomes included the need for rescue analgesics during the surgery, and related complications such as nausea, vomiting, pruritus, hypotension and bradycardia. We conducted meta-analysis with the Review Manager, version 5.3 , applying trial sequential analysis (TSA) software version 0.9.5.5 beta  of each outcome. The cumulative z-curve was constructed using a random-effects model. We set the 95% confidence intervals adjusted for scattered data and repetitive testing.TSA combines information size estimation for meta-analysis  with an adjusted threshold for statistical significance in the cumulative meta-analysis which called trial sequential monitoring boundaries−1 or 12.5 mg (Group I), or dose more than 0.2 mg kg−1 or 12.5 mg, up to 0.5 mg kg−1 or 25 mg (Group II).For each study, we conducted subgroup analyses by pooling estimates of various surgery types and different dosage adjuvant intrathecal meperidine. Studies of low dose adjuvant intrathecal meperidine was further divided into two groups: dose equal to or less than 0.2 mg kgWe conducted meta-regression to assess the relationship between one or more covariates (moderators) and primary outcome. In this study, potential covariates such as age, meperidine dose, and sample size of each study will be evaluated to determine whether they are the source of heterogeneity.We conducted sensitivity analyses to evaluate methodological quality, participants and spinal anaesthesia techniques to test the stability of the integration effect and to assess statistical heterogeneity. Regarding the quality assessment, bias of selection, performance, detection and attrition were excluded. If random sequence generation and allocation concealment were both unclearly reported or any were categorized as high-risk, we counted this as selection bias.Among 2373 initially evaluated abstracts, 227 studies met the initial inclusion criteria Fig. , 199 tri59. Three studies were published in Korean56, two were in traditional Chinese49, and two were in simplified Chinese43, one was in Turkish50, and the remaining 20 were published in English. The sample sizes ranged from 40 to 195 patients. There are 15 RCTs of obstetric patients receiving caesarean section surgery59, 4 trials enrolled urological surgery55, and the other 9 focused on lower abdominal or lower limb surgery54. Intrathecal local anaesthetics plus meperidine group was compared with the same dose local anaesthetics alone49 or with normal saline59 or with 10% glucose water33 as controls.Published from1984 to 2016, the characteristics of the 28 RCTs with 2216 participants were shown in Table 58, three trials interrogated it with intrathecal morphine54 and one with intravenous ondansetron30. Two trials added morphine for both the experimented and the controlled57, while one contained epinephrine58. Eight studies investigated various doses of intrathecal meperidine59. In terms of the intrathecal local anaesthetic drug, bupivacaine was used in 21 studies59, lidocaine in 5 trials58, and tetracaine in 2 RCTs49. Intravenous sedation was combined with spinal anaesthesia in 4 studies54, and prehydration was neither given nor disclosed in 4 trials54. Ten RCTs did not provide information on hypothermia prevention58. Patient characteristics, spinal anaesthesia techniques and surgical procedures are summarized in Table Five studies evaluated the anti-shivering effects of intrathecal fentanyl with meperidine59, while one had poor quality29 and the rest were unclear. How allocation concealment was carried out was clearly described in 11 RCTs59. Performance bias was found in 5 studies54, while detection bias was identified in 13 trials59. Two studies performed a per-protocol analysis, and 7 patients were withdrawn in total during the follow-up periods45. Other biases included differences in shivering assessment scales49, existence of data error59, combination with epidural anaesthesia43, and nondisclosure of intraoperative shivering data31 and spinal needle size43.The quality assessment of RCT methodology is shown in Supplementary Table 59 (n = 1535) was significantly reduced in the adjuvant low dose meperidine groups when compared with control, with an RR of 0.31   have further evaluated the preventive effect of adjuvant low dose intrathecal meperidine to the incidence of shivering based on a 4-level intensity scale60, showing that the RRs were 0.62  for grade I, 0.35  for grade II, 0.26  for grade III, and 0.15  for grade IV shivering  , RRR 73.3%, ARR 10.6%, and NNTs 9.5 , and in vomiting with RRs of 2.23    and 1.16 , respectively. However, their TSA required information size were not reached and their z-curves did not cross the conventional boundary: TSA adjusted 95% CI cannot be calculated due to too little information on bradycardia , and TSA adjusted RR, 1.15  on hypotension  in caesarean section, 0.30  in lower limb orthopaedic surgery, 0.11  in urology, and 0.42  in other miscellaneous surgical patients, respectively. The benefit of reducing the need of rescue analgesics and the morbidities of nausea and vomiting were only noted in the subgroup of caesarean section. The subgroup analysis of intervention dose indicated that dose equal to or less than 0.2 mg kg−1 or 12.5 mg (Group I) could provide similar anti-shivering and analgesic effect  as dose more than 0.2 mg kg−1 or 12.5 mg, up to 0.5 mg kg−1 or 25 mg (Group II) in comparison with the control , 2.68 (P = 0.42), and 0.007 (P = 0.33), respectively  were related to the adjuvant opioid or reduced local anaesthetic was unclear62. Thus comparing meperidine as adjuvant under an equal amount of intrathecal local anaesthetics guided our meta-analysis design. Feng. et al. investigated primarily sulfentanil and showed no beneficial effect while also revealing increased the incidence of pruritus63. Shortcomings of that study included mixed use of spinal and epidural anaesthesia and mixed local anaesthetic drugs which have been carefully avoided in our sensitivity analyses63. Therefore, our results on intrathecal meperidine for the prevention on shivering under spinal anaesthesia would be more reliable due to meticulous management of this bias.Previous studies noted the anti-shivering effect of intrathecal opioids8, and blunts thermoregulatory processing3 leading to vasodilation, heat loss and hypothermia: all these factors might contribute to shivering. Meperidine is the most common intravenousdrug used for treating and preventing shivering, as its equi-analgesic dose is much more efficient than other opioids such as fentanyl, alfentanil, sufentanil or morphine in preventing shivering65. Meperidine is the only opioid that is an agonist at both the μ and κ receptors closely related to the pathogenesis of shivering by reducing the shivering threshold and triggering decreasedcore temperature, constitutes its anti-shivering effect67.The mechanism of shivering during spinal anaesthesia is multifactorial. Sympathetic blockade caused by spinal anaesthesia impairs compensatory vasoconstriction and autonomic regulation below the level of the blockade71. The increased incidence of nausea and vomiting associated with intrathecal meperidine may relate to several issues. First, intrathecal meperidine could be deemed as an analgesic independently, so a higher level of anaesthesia might cause systemic hypotension, nausea and vomiting when adjuvant was given. However, none of our recruited studies had significant differences regarding anaesthetic level between the control and the meperidine group. Future studies could focus on the optimal dose of local anaesthetics and intrathecal meperidine and possible interactions. Furthermore, like morphine and other opioids, intrathecal meperidine also showed its central effect inducing nausea and vomiting72.Nausea and vomiting are common opioid-related side effects, but their mechanisms are extremely complex76. The sensitivity analyses illustrated that both therapeutic and adverse effects of intrathecal meperidine are unaffected by anaesthetic techniques, perioperative care, and patient age or physical status. The benefit of reduction of rescue analgesic in low dose intrathecal meperidine with less nausea and vomiting could not be generalized to all surgeries due to the limited RCTs included. Furthermore, reducing meperidine dosages could not prevent nausea and vomiting as anticipated. Thi. et al. showed that the dose-dependent analgesic effect of intrathecal meperidine lower than 0.5 mg kg−1 would not aggravate nausea and vomiting24. Although we demonstrated that dose equal to or less than 0.2 mg kg−1 or 12.5 mg could provide anti-shivering and adequate analgesia as effective as dose more than 0.2 mg kg−1 or 12.5 mg, an optimal dose of low dose intrathecal meperidine was not yet identified. Since the benefits of shivering protection and rescue analgesics reduction were not overwhelmed by nausea and vomiting, the potential utility of such interventions could be considered in clinical practice.Subgroup analyses demonstrated that the protective effect of adjuvant low dose intrathecal meperidine against shivering was demonstrated among caesarean section, urological, other lower abdominal and lower limb orthopaedic surgeries. It is particularly beneficial to elderly and obstetric patients who are vulnerable to shivering-induced oxygen consumption, metabolic demands and cardiovascular morbidities41 reducing possible influence from selection reporting bias. We analysed the incidence of shivering as well as the effect on different grades of shivering, conducted sensitivity analyses to improve the reliability of our results, and performed TSA to reduce systematic and random errors and identify the threshold of statistical significance61. TSA was applied to account for scattered data and repetitive testing on accumulated data, to calculate the required information size, and to confirm the cumulative z-curve crossing the boundary of benefit or harm in the listed outcomes61. This meta-analysis with TSA provided us robust results and indicted that no further trials about adjuvant intrathecal meperidine on shivering prevention are needed in the current future. This is the first systematic review and meta-analysis using TSA to validate the benefits and harms of intrathecal meperidine for patients undergoing spinal anaesthesia.The are several strengths to this review. Using Cochrane methodology for a non-restricted up-to-date literature search without limitation by language or country of publication (8 countries and 5 languages) is one of our major strengths. We also attempted to correct publication bias using the’trim and fill’ method79. Third, local anaesthetics per se used in spinal anaesthesia could induce sympathetic blockade, hypotension and nausea/vomiting, which might interfere with observations regarding side effects induced by intrathecal meperidine. Fourth, although subgroup analysis for types of surgeries has been considered, caesearean section surgeries contributed the majority of the database. The application of the study outcome to other surgeries needs to be further evaluated.Our study has several limitations. First, although various biases among all RCTs included have been considered under sensitivity analysis and three possible covariables were also assessed by meta-regression, results remained moderately heterogenious and other covaribles were unidentified. This implies that the conclusion needs to be carefully intepreted and applied in clinical practice due to the existence of qualitative and statistical heterogeneity for our overall incidence of shivering as well as specific findings such as pruritus, nausea and vomiting. Second, as this study specified single medication through single route,the dose-response effect of adjuvant intrathecal meperidine with local anaesthetics remains unclear and needs further investigation using network meta-analysisOur meta-analysis with TSA validates the effectiveness of shivering prevention by adjuvant low dose intrathecal meperidine with local anaesthetics for spinal anaesthesia with reduced intraoperative need for rescue analgesics, but it also noted increased incidence of nausea and vomiting. Further larger RCTs or network meta-analyses are needed to evaluate different doses of intrathecal meperidine as well as other routes of administration to help anaesthesiologists provide better care in clinical practice.Supplementary Information


To the Editor: On April 9, 2016, a 32-year-old woman from Italy traveled to Santo Domingo in the Dominican Republic. She worked as a volunteer nurse in the outpatient clinic of a primary school of a nongovernmental organization based in Italy. She returned to Italy on April 17. She did not have sexual intercourse during her stay abroad. On April 26, she was referred to the travel clinic of the National Institute for Infectious Diseases Lazzaro Spallanzani in Rome for a febrile syndrome with rash, generalized headache, and weakness, which started on April 21. Approximately 24 hours later, she was admitted to the institute’s medical facility for a suspected neurologic involvement. At admission, she had abnormal gait, strong asthenia, and a disseminated pruritic rash on her face, abdomen, chest, and arms, but she did not have a fever.During physical examination, the patient was alert and fully oriented. Temperature was 36.9°C, pulse rate 90 beats/min, blood pressure 100/60 mm Hg, and respiratory rate 20 breaths/min. She had a diffuse erythematous macular rash and bilateral nonpurulent conjunctival hyperemia without meningeal signs. Findings of a neurologic examination of the upper limbs were within reference ranges.. Muscular strength was reduced in both legs (left > right), whereas tendon reflexes and all sensory modalities were within reference ranges. Results of a contrast-enhanced magnetic resonance imaging of the brain and spinal cord (on day 7), nerve conduction studies and electromyography (on day 8), and an electroencephalogram (on day 16) were within reference ranges. A lumbar puncture (on day 7) showed normal cell counts (<10 cells/mL), a normal glycorrachia/glycemia ratio (>0.5), and a slight increase in protein concentration (0.48 g/L [reference range 0.32−0.80 g/L]) in cerebrospinal fluid. Complete neuropsychologic examinations (on days 9 and 10) showed mild deficits in attention and mental processing speed and mental flexibility and moderate deficits in verbal and nonverbal memory tasks .Real-time reverse transcription PCR (rRT-PCR) results for dengue viruses 1–4 and chikungunya virus were negative in serum and cerebrospinal fluid (CSF), whereas Zika virus RNA was detected in serum (day 7), urine (up to day 27), CSF (day 6), saliva (up to day 13), and vaginal swab (up to day 13) . SpecifiStarting on day 7, intravenous polyvalent immunoglobulins were administered (0.4 g/kg/day for 5 days); no adverse events were observed. A second neuropsychologic examination was performed on day 16 and indicated persistent impairment in memory performances and an improvement in mental concentration and flexibility tasks .A second lumbar puncture (on day 17) showed an increased cell count , and CSF was negative for Zika virus RNA by rRT-PCR. The patient was discharged on day 20; she showed a progressive neurologic recovery starting on day 16. At 60-days follow-up visit, no neurologic deficits were reported.During the 2013–2014 outbreak of Zika virus in French Polynesia and in the context of the 2015–2016 Zika virus circulation (In our patient, Zika virus RNA was found in different systems, including the central nervous system and the genital tract. Recently, a mouse model of Zika virus infection by vaginal exposure demonstrated that Zika virus replicated within the genital mucosa, persisted postinfection, and was detected in the fetal brain of the mice (Our case highlights the potential for Zika virus neurotropism and the need for early identification of Zika virus–related neurologic symptoms. Moreover, the presence of Zika virus in the genital tract supports the recommendation of safe sex practice for women returning home from areas with ongoing Zika virus transmission.Methods for laboratory diagnosis and neuropsychologic examination.


The proportion of early gastric cancer stages is increasing, as is the incidence of gastric cancer among the elderly population. Therefore, this study was designed to analyze surgical treatment outcomes of T1-T2 gastric cancer in elderly patients.A total of 457 patients with T1-T2 gastric cancer who underwent gastrectomy between 2005 and 2015 were enrolled in this retrospective study. Patients were classified into two groups according to age (< 70 years versus ≥ 70 years). Clinicopathological features, surgical treatment results, and clinical outcomes were compared between the groups.Higher ASA score (ASA 3/4), differentiated cancer, and intestinal-type tumors were more common in elderly patients. Postoperative complication rates were similar between the two groups; however, postoperative mortality rates were significantly higher in the elderly group. Higher ASA score was independently associated with postoperative complications in the elderly group. Furthermore, severe postoperative complications were found as an independent factor associated with higher 90-day mortality rate. Elderly patients had a significantly poorer 5-year overall survival rate. Two surgery-related factors—total gastrectomy and complicated postoperative course—were revealed as independent prognostic factors for poor overall survival in the elderly group.Despite higher postoperative mortality rate and poorer overall survival results, elderly patients with gastric cancer should be considered for radical surgery. ASA score may be useful for predicting surgical treatment outcomes in elderly patients undergoing surgery for GC and hence assists clinicians in planning treatment strategies for each individual patient. Even though the incidence of gastric cancer (GC) has decreased over the past decades, it continues to be a major healthcare problem being the fourth most common malignancy and the second cause of death among all cancers . TreatmeThe aim of our study was to analyze the differences in surgical treatment outcomes between elderly and non-elderly patients with early invasion (pT1-T2) gastric cancer.A total of 1654 patients diagnosed with gastric adenocarcinoma underwent surgery at the National Cancer Institute, Vilnius, Lithuania, between 2005 and 2015. One thousand one hundred ninety-seven patients who received gastrectomy for pT3-4 gastric cancer or received neoadjuvant chemotherapy prior to surgery were excluded from the study. The remaining 457 patients who underwent gastrectomy for pT1-2 gastric cancer were included into the final analysis.Surgical procedures were performed as described in our previous report . Based oAll patient characteristics were obtained from their medical records and prospectively collected database. Tumor stage was coded according to the TNM system as described in the Union Internationale Contre le Cancer/American Joint Committee on Cancer 7th edition. Demographic characteristics included age and sex. Clinicopathological characteristics included smoking status, body mass index (BMI), comorbidities, American Society of Anesthesiology (ASA) score, hospitalization and intensive care unit (ICU) time, type of surgery and lymphanodectomy, length of surgery, blood loss, tumor location, tumor size, differentiation, depth of invasion, lymphovascular invasion, and retrieved and metastatic lymph node count. Postoperative morbidity and mortality were evaluated. All postoperative complications were graded according to Clavien-Dindo classification.OS analysis was performed. OS was defined as time from surgery to death. Data of survival and date of death were collected from Lithuania’s Cancer register and Lithuania’s death register . The last test, one-way ANOVA test, chi-square test, Fisher exact test, or non-parametric tests. All potential risk factors for postoperative mortality and morbidity were included in subsequent multivariate logistic regression analyses. Independent variables associated with postoperative morbidity and mortality were identified. OS analysis was performed by the Kaplan-Meier method. Survival curves were compared by the log-rank test. Multivariate survival analysis was performed using the Cox proportional hazards model . In all statistical analyses, a p value of < 0.05 was considered to be significant.Statistical package SPSS 16.0  was used for statistical analysis. Groups were compared by a two-tailed At the time of surgery, 267/457 (58.4%) patients were younger than 70 years. One hundred ninety 41.6%) patients were 70 or older. Table .6% patiep = 0.001) and intestinal type tumors according to Lauren classification . Poorly differentiated tumors were more common in the NE group .Significant differences were found between the groups in terms of physical status (ASA score), histological type of tumor, and tumor differentiation grade. Significantly larger proportion of elderly patients had severe systemic diseases (ASA 3–4) . Furthermore, fatal complications which led to postoperative deaths were observed only in elderly patients, and the mortality rate was significantly higher in this group . Even higher differences were observed when 30- and 90-day mortality rates were compared. First deaths in NE group were observed between 30th and 90th postoperative days with the 90-day mortality rate reaching 2.6%. During the same time period, mortality rate in the E group increased from 7.4 to 12.6% and remained significantly higher when compared to the NE group.The short-term surgical outcomes are shown in Table p = 0.006), total gastrectomy (p = 0.022), and multivisceral surgery (p = 0.031) were identified as factors that were associated with postoperative complications in the E group (Table p = 0.021).At univariate analysis, ASA III/IV , 14.9 vs. 4.3%, p = 0.034) and tumor localization in the upper third (p = 0.013) were associated with 90-day mortality in the NE group.While there were no deaths in the NE group during first 30 postoperative days, factors associated with 90-day mortality rate were analyzed. At univariate analysis, ASA 3/4 (p = 0.038) and multivisceral surgery (p = 0.017) as factors associated with death during the first 90 postoperative days. With multivariate analysis, only severe complications during hospitalization were found as independent factors associated with higher 90-day mortality rate .In the E group, univariate analysis revealed ASA 3/4 (p = 0.001). However, we did not found a significant difference in postoperative complications rate after surgery for upper third tumors between the NE and E groups . However, in contrast to most Western and Japanese reports [There was no significant difference in the overall and surgical postoperative complication rate between the NE and E groups. These results oppose studies published in the early 2000s, where age was shown to be a major predictor of postoperative complications or mortality . Instead reports –26, we fOther well-known surgical risk factors for postoperative morbidity are the extent of gastric resection  and multivisceral resection , 25, 26.Even though the rate of total complications was comparable between the study groups, we found significantly higher number of medical complications in the E group. Furthermore, 5.7% of elderly patients died after postoperative complications occurred, while there were no deaths in the NE group. Hayashi et al. reported similar results , in whicIn determining the appropriate treatment for each individual, patient prognosis should also be considered before turning to surgery. Many studies have specifically compared the long term-outcome of GC in elderly patients with non-elderly. Most of these have confirmed that the prognosis for elderly patients was poorer , 31, 32.Contrary to the predictive factors determined in the NE group, we failed to find any patient or tumor-related links to poor OS results in the E group. Although total gastrectomy and postoperative complications were two independent risk factors of decreased OS in the E group, both of them were related to the surgery itself. We hypothesize that with a total gastrectomy, poor OS results are due to the prolonged duration of surgery and more extensive intraabdominal manipulations, which can result in higher risks of postoperative complications and deaths in early postoperative period. Furthermore, Mantovani et al.  suggesteElderly patients with early invasion of GC have a similar risk of postoperative complications as the non-elderly population. However, they should receive special attention in cases of complicated postoperative courses because mortality rates in the elderly are significantly higher.Our study suggests that the ASA score may be useful in predicting postoperative complications in elderly patients undergoing surgery for GC. It offers clinicians another tool in optimizing treatment strategies. Finally, our results suggest that radical surgery with at least limited lymph node dissection should be considered, even for elderly patients.


Background. Glial cells are implicated in the development of chronic pain and brain-derived neurotropic factor (BDNF) released from activated microglia contributes to the nociceptive transmission. Neural mobilization (NM) technique is a method clinically effective in reducing pain sensitivity. Here we examined the involvement of glial cells and BDNF expression in the thalamus and midbrain after NM treatment in rats with chronic constriction injury (CCI). CCI was induced and rats were subsequently submitted to 10 sessions of NM, every other day, beginning 14 days after CCI. Thalamus and midbrain were analyzed for glial fibrillary acidic protein (GFAP), microglial cell OX-42, and BDNF using Immunohistochemistry and Western blot assays. Results. Thalamus and midbrain of CCI group showed increases in GFAP, OX-42, and BDNF expression compared with control group and, in contrast, showed decreases in GFAP, OX-42, and BDNF after NM when compared with CCI group. The decreased immunoreactivity for GFAP, OX-42, and BDNF in ventral posterolateral nucleus in thalamus and the periaqueductal gray in midbrain was shown by immunohistochemistry. Conclusions. These findings may improve the knowledge about the involvement of astrocytes, microglia, and BDNF in the chronic pain and show that NM treatment, which alleviates neuropathic pain, affects glial cells and BDNF expression. Nerve injury in humans often results in persistent or chronic neuropathic pain which is characterized by spontaneous burning pain accompanied by hyperalgesia and allodynia . The occMany studies have demonstrated the involvement of glial cells  in both The NM technique is a noninvasive manual therapy method used by physiotherapists to treat patients with pain of neural origin, such as the pain caused by compression of the sciatic nerve. Previous studies from our group have demonstrated the efficacy of this technique in relieving induced neuropathic pain in rats . The tecAs our group has previously demonstrated the NM technique's efficacy in relieving pain-related behaviors, our goal here was to evaluate the central involvement of glial cells and brain-derived neurotrophic factor in the thalamus and midbrain of neuropathic rats that had received NM therapy.Male Wistar rats weighing between 200 and 220 g (2 months old) were used in all experiments. The rats were housed five per cage and maintained on a 12 : 12 h light/dark cycle. The rats were adapted to the experimental environment three days before the experiments began. All animals were tested during the light cycle at the same time of day (9:00 a.m.–14:00 a.m.). All procedures were approved by the Institutional Animal Care Committee of the University of São Paulo . Efforts were made to minimize the number of animals used and their suffering.To induce neuropathic pain, chronic constriction of the sciatic nerve was performed as previously described by Bennett and Xie in 1988 . BrieflyThe NM technique used here has been described by Butler (1991) and adapted by our laboratory , 24. BriN = 5/group). Neuropathic (CCI), sham and naive rats were sacrificed by decapitation under light isoflurane anesthesia. The thalamus and midbrain were quickly removed and homogenized in an extraction buffer containing 100 mM Tris, 10 mM EDTA, 2 mM PMSF, and 10 μg/mL aprotinin at a pH of 7.4. After extraction, the homogenates were centrifuged at 11.5g for 20 min, and the protein concentrations of the supernatants were determined using the Bradford protein assay with albumin as the standard (Bio-Rad) [μg of protein were loaded on 12% acrylamide gels and electrotransferred onto nitrocellulose membranes using a Bio-Rad miniature transfer apparatus for 1.5 h at 120 V. After transfer, the membranes were treated for 2 h at room temperature with a blocking solution containing 5% powdered milk, washed, and incubated overnight at 4°C with an anti-GFAP , a monoclonal anti-OX-42 , or an anti-BDNF . The membranes were then washed and incubated for 2 h at room temperature with a peroxidase-conjugated, anti-rabbit secondary antibody and diluted 1 : 5000 (ZIMED Laboratories Inc.) with anti-mouse secondary antibody . β-Actin was used as an internal control . The specifically bound antibody was visualized using a chemoluminescence kit (Amersham Biosciences). The blots were analyzed densitometrically using NIH-Scion Image 4.0.2 and quantified with optical densitometry of the developed autoradiographs .Western blotting analyses were performed on samples from individual animals (Bio-Rad) . SamplesThe animals were deeply anesthetized with ketamine  and xylazine  and perfused through the left cardiac ventricle with phosphate buffered saline at 37°C and 4% paraformaldehyde in cold 0.1 M phosphate buffer (PB), pH 7.4. Brains were dissected out and postfixed for 2 h. After this period, they were kept in a cryoprotective 30% buffered sucrose solution in PB for at least 4 h until sectioning.μm) were obtained on a sliding microtome adapted for cryosectioning. The sections were incubated free-floating for 12–16 h with GFAP , OX-42 , and BDNF  all of them diluted 1 : 1000 in 0.3% of Triton X-100, containing 0.05% goat normal serum.The brain sections  and then with the avidin-biotin complex . After washing, the sections were reacted with 0.05% 3,30-diaminobenzidine and 0.01% hydrogen peroxide in PB. Intensification was conducted with 0.05% osmium tetroxide in water. The sections were mounted on gelatinized slides, dehydrated, cleared, and cover-slipped.CCI, CCI, with NM and naive animals (used as controls) were evaluated. Controls for the immunohistochemistry experiments consisted of the omission of primary antibodies, and no staining was observed in these cases. The material was analyzed on a light microscope and digital images were collected. Figures were mounted with Adobe Photoshop CS. Manipulation of the images was restricted to threshold and brightness adjustments of the whole image.p < 0.05 was considered statistically significant [Statistical analyses of the data were performed with GraphPad Prism, version 4.02 (GraphPad Software Inc.). All data are expressed as the mean ± SEM. Statistical comparisons of more than 2 groups were performed with analyses of variance (ANOVAs), and differences between means were tested using Tukey's tests. In all cases, nificant .p > 0.05) of the rats that received NM treatment (CCI-NM) compared to the CCI group , respectively  after CCI injury compared to naive animals. Moreover, decreases in BDNF expression in thalamus and midbrain of 36% and 41% (p > 0.05), respectively, were observed after NM treatment (CCI-NM)  , 29. WheOur results revealed increases in glial cells (GFAP and OX-42) in the thalamus and midbrain after CCI injury relative to the control groups . In contrast, when the animals received neural mobilization treatment, we observed the inverse result; that is, we observed decreases in GFAP  and OX-42  expression compared to the CCI group that did not receive treatment; these results suggest that these cells were involved in our model. Our findings corroborate the findings of other studies showing an increase of GFAP expression after CCI injury and a decrease after administration of the N-methyl-D-aspartate (NMDA) receptor antagonist , 45 or tStudies have reported that, after nerve injury, neuronal metabolism is altered such that protein synthesis is increased to support the regenerative roles of neurotrophins such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF); both of these neurotrophins act to regulate the growth and hence survival of sensory neurons , 51. RecIn summary, the increased optical densities for astrocytes, microglia, and BDNF that we observed in the thalamus and midbrain after CCI injury were reversed by neural mobilization treatment. Other treatments were able to decrease the BDNF after pain conditions, as shown with the transcranial direct current stimulation technique on pain behavior and BDNF levels in ovariectomized rats . And swi


Angelica sinensis (RAS) is a traditional Chinese medicine used for preventing and treating various diseases. In this study, we assessed RAS supplementation effects on body weight and the FTO gene expression and methylation status in a high-fat-diet (HFD) induced obese mouse model. Female obese mice were divided into groups according to RAS dosage in diet as follows: normal diet, HFD diet (HC), HFD with low-dosage RAS (DL), HFD with medium-dosage RAS (DM), and HFD with high-dosage RAS (DH). After RAS supplementation for 4 weeks, body weight suppression and FTO expression in DH mice were significantly higher than in HC mice, whereas no significant change in FTO expression was detected between DM and DL mice or in their offspring. Bisulfite sequencing PCR (BSP) revealed that the CpG island in the FTO promoter was hypermethylated up to 95.44% in the HC group, 91.67% in the DH group, and 90.00% in the normal diet group. Histological examination showed that adipocytes in the DH group were smaller than those in the HC group, indicating a potential role of RAS in obesity. This study indicated that RAS could ameliorate obesity induced by HFD and that the molecular mechanism might be associated with the expression of the FTO gene.The root of Sibiraea angustata could effectively ameliorate obesity by inhibiting the synthesis, growth, and accumulation of fatty acid in adipocytes [ in vivo in mouse models of high-fat-diet (HFD) induced obesity [Obesity is a global health priority and resistance to diet induced obesity has been studied in many animal models. A diet rich in sugar and containing up to 45% fat has been widely used to induce obesity in mice –3. Scienipocytes . The fun obesity . Angelica sinensis (Chinese named Danggui), a well-known herbal medicine, has been historically used as a tranquilizer or a tonic agent [ Angelica sinensis polysaccharide (ASP), the active chemical components of RAS, had hematopoietic effects in animal and cellular models [The root ofic agent , 9. As ar models . Two acir models . Furtherr models . (FTO) gene has a relative effect on obesity [ FTO is located on chromosome 16 in humans and encodes a protein with a double-stranded b-helix fold, homologous to the members of the nonheme and 2-oxoglutarate oxygenase superfamily (which mainly impact the metabolism of fatty acid) [ FTO is involved in food intake regulation and lipid metabolism [ FTO mRNA and protein in the hypothalamic nucleus was of critical importance in the regulation of feed intake in mice [ FTO in mice led to postnatal growth retardation and a significant reduction in adipose tissue and lean body mass [ FTO, however, led to a dose-dependent increase in body and fat mass [ FTO influences adipogenesis by regulating the process of mitotic clonal expansion in obese mice [The fat mass and obesity associated obesity . FTO is ty acid) . Furthertabolism . Histoloody mass . Over exfat mass . Furtherese mice . FTO gene were determined to compare the effects of RAS between control and treated groups. This study will provide a foundation for understanding the functions of RAS in obesity resistance.In the present study, we assessed the effects of RAS supplementation on body weight in HFD mice. Furthermore, mRNA expression and promoter methylation status of theAnimas involved in this study were sacrificed according to the Regulations for the Administration of Affairs Concerning Experimental Animals and approved by the Institutional Animal Care and Use Committee at the College of Animal Science and Technology, Sichuan Agricultural University, Sichuan, China, under the permit number DKY-B20110807.n = 10) or the HFD group  without RAS supplementation. After 5 weeks, the obese mice were randomly divided into four groups. All groups were continually fed with HFD. The first group (n = 12) was designated the high-fat control group (HC) without RAS supplementation. The second group (n = 11) received RAS supplementation at 2.00 g/kg·BW and was designated as the low-dose group (DL). The third group (n = 11) received RAS supplementation at 5.00 g/kg·BW and was designated the medium-dose group (DM) and the last group (n = 12) was designated the high-dose group (DH) with RAS supplementation at 10.00 g/kg·BW. The female offspring were obtained by mating with the male KM fed under same conditions for each group. The diet formula is shown in Female KM mice at 5 weeks of age were obtained from the Chengdu Dossy Laboratory Animal Co., Ltd, in Sichuan province, China. Mice were reared at standard conditions within a free access to food and water for 1 week to acclimatize to experimental conditions. Mice were then randomly assigned to the normal diet group . The purity of the isolated RNA was determined by agarose gel electrophoresis and the concentration was quantified by the ND-2000 Nanodrop . cDNA was synthesized using the Prime Script RT reagent Kit  according to the manufacturer's recommendations. FTO in adipose tissues of mice from GC, HC, DL, DM, and DH groups, as well as DH offspring. Primer pairs used for qPCR ( FTO gene (NM_011936). The qPCR was performed in triplicate using a SYBR® Premix Ex Taq™ II kit . Each qPCR reaction  contained 0.8 μL cDNA, 5 μL SYBR Green II, 0.8 μL primer pairs, and 3.4 μL ddH2O. The qPCR procedures were as follows: 95°C for 3 min, 40 cycles of 95°C for 10 s, 30 s at optimum temperatures, 72°C for 10 s, and a final extension for 5 min, and then a temperature increment of 0.5°C/s from 65°C to 95°C to build a melting curve. The specificity of qPCR products was confirmed by melting curve analysis. The relative expression of FTO mRNA was determined using the geometric mean of GAPDH, β-actin, and 18s rRNA by the 2−ΔΔCT method [We performed quantitative real-time PCR (qPCR) to quantify the relative mRNA expression levels offor qPCR  were desT method .Genomic DNA was extracted from the adipose tissues of mice from GC, HC, and DH groups after RAS supplementation for 35 days, using TIANamp Genomic DNA Kit . Three animals were randomly selected from each group. DNA was quantified by the ND-2000 Nanodrop and then treated with sodium bisulfite using the EZ DNA Methylation Gold Kit . Following the manufacturer's instructions, DNA dosage was strictly limited to insure complete cytosine to uracil conversion. FTO promoter (Acc. number AC105989) were estimated by the online program (http://www.urogene.org/cgi-bin/methprimer/methprimer.cgi). The primer pairs were modified by Primer Premier 5 , and 30 s at 72°C, and a final extension for 7 min at 72°C. The second PCR products were purified with a DNA Gel Extraction Kit  and then ligated into pMD 19-T vector . At least ten positive recombinants were sequenced on an ABI 3730XL DNA analyzer . The methylated CpGs were analyzed with the QUantification tool .The methylated CpGs in theremier 5 . The PCRThe abdominal adipose tissues were resected and fixed in 4% paraformaldehyde after washing. They were then dehydrated in ethanol and soaked in dimethylbenzene and then embedded in paraffin. The tissue blocks were sectioned at 4-micron thickness and then stained with haematoxylin and eosin (H&E) reagent. Photomicrographs were obtained and analyzed using Image-Pro Plus software (Media Cybernetics).t-test.All of the statistical analyses were performed using SPSS 20.0  and the data were represented as means ± SD. The significance between groups was estimated by a one-way ANOVA test and Student's Compared with the normal diet group (GC), the HC mice showed marked obesity after feeding with HFD for 5 weeks . During  FTO mRNA expression, we performed qPCR to quantify FTO expression in adipose tissues collected from mice in the GC, HC, DL, DM, and DH groups at days 35 and 60. In addition, we also determined FTO expression in HC and DH mice at day 95, as well as in their progeny at day 35. The qPCR results showed that the expression of FTO in the RAS-supplemented groups  was significantly higher than in the HC group after both 35 d and 60 d , while the mice fed with HFD showed a higher methylation level in the HC group (95.44%). As expected, supplementation of RAS reduced the methylation level, which reached 91.67% in DH mice.The structure of the analyzed CpG sites and their locations (GenBank Acc. number AC105989: 31474–31968) within theμm and 227.7 ± 48.2 μm, respectively, and adipocyte area was 115,817.8 ± 38,956.0 μm2 and 44,655.3 ± 19,589.2 μm2, respectively .The H&E histological examination showed that adipocytes had a polygonal morphology with typical peripherally located nuclei and distinct cell borders . After bectively . In the  FTO gene in mice with HFD obesity. As many previous studies, the obesity mouse model was induced by HFD; while formulas differ between studies, common ingredients included sugar and lard [In this report we demonstrate, for the first time, the favorable effects of RAS supplementation on body weight, gene expression, and promoter methylation of theand lard , 2. The and lard , 21. In  FTO mRNA was significantly increased in RAS-supplemented mice  and body weight gain of HC mice was markedly higher than that of DL, DM, and DH mice. This suggests that RAS might influence BW gain via alterations of gene expression. As showed by qPCR, there was a significant difference in FTO expression between RAS-supplemented groups and the GC and HC groups in 35 d, suggesting a correlation between FTO expression and body weight gain. In HC mice, however, FTO expression was lowest and obesity was highest. Previous studies reported that loss of FTO in mice resulted in a significant reduction of adipose tissue and lean body mass [ FTO influenced adipogenesis by regulating events early in adipogenesis during the process of mitotic clonal expansion [ FTO mRNA was more highly expressed in RAS-treated groups than the control group, especially the DH group. After 60 d, the highest FTO expression level was in the RAS-treated groups. Moreover, no significant difference was observed after 95 d between the GC and HC groups, or in their offspring. These results suggest that the effects of RAS supplementation on FTO expression are not heritable.We found that the expression ofody mass , and thaxpansion . FTO mRNFTO is a nucleic acid demethylase that removes methyl groups from both DNA and RNA [ FTO promoter region. There are 15 CpG dinucleotides present in the 2 Kb upstream of the start codon of FTO. BSP results showed that the CpG sites within the FTO promoter were highly methylated in all of the three groups . Although the methylation levels were not significantly different, our results revealed that promoter methylation and expression of FTO gene mRNA were negatively correlated. Thus, regulation by a methyl group blocking the transcription factor binding to this region  is possible. and RNA , 22. Pre and RNA . The mod Angelica sinensis in ameliorating glucose and lipid metabolism disorders related to obesity, possibly due to interactions with insulin and serum inflammatory factors [Previous study has demonstrated the polysaccharide of factors . The mol FTO mRNA expression, and reduction of methylation. The present study provides new insights into the biological role of RAS. Further detailed analyses need to be performed to understand the mechanism of RAS in body weight suppression.This study investigated whether RAS could suppress body weight in HFD obese mice. The supplementation of RAS was associated with suppression of body weight, increased


All signal alterations were hyperintense on T2-weighted images and iso- or hypointense in T1-weighted images. Signal void in T2* was not observed in any dog. Postcontrast sequences were available in 30 of the 37 dogs and showed enhancement in 45%. There was neither an association with degree of compression nor epidural hemorrhage. Intervertebral disk extrusion caudal to L1 and a higher neurological grade was associated with the presence of muscle changes. Histopathology revealed mild to moderate acute muscle fiber degeneration with edema and necrosis in three of five samples. The MRI, as well as the muscle samples, show rather unspecific changes. The underlying pathomechanism might be related to ischemia or muscle spasm, but also denervation edema may explain the signal alteration.Muscle signal alteration detected on MRI is seen in diverse pathologic conditions. We observed signal alterations within the paraspinal muscles in dogs with acute thoracolumbar intervertebral disk extrusion. The aim of this retrospective study was to describe MRI features of paraspinal muscle signal alteration in dogs with acute thoracolumbar intervertebral disk extrusion and to investigate an association of the signal alterations with neurological grade, type and location of intervertebral disk extrusion, degree of spinal cord compression, and presence of epidural hemorrhage. Medical records of dogs undergoing MRI because of thoracolumbar intervertebral disk extrusion between August 2014 and June 2016 were reviewed. MRI was evaluated for SI changes within the paravertebral musculature, their location, extension, affected muscles, contrast enhancement, and signal void in T2* sequences. Intervertebral disk herniation was categorized as acute non-compressive nucleus pulposus extrusion (ANNPE) or compressive intervertebral disk disease. In five patients, muscle biopsies of areas with signal intensity changes were taken during surgery. In total, 103 dogs were enrolled in the study. Paraspinal muscle signal alterations were visible in 37 dogs (36%) affecting the epaxial musculature ( Magnetic resonance imaging (MRI) signal intensity of normal skeletal muscle is generally slightly higher than that of water and much lower than fat on T1-weighted (T1W) images and much lower than both fat and water on T2-weighted (T2W) images , associaIn dogs with acute intervertebral disk herniation, we previously observed signal alterations with an edematous pattern in the paravertebral muscles. To the best of our knowledge, this finding has not been reported in the current literature. Therefore, the first aim of this retrospective study was to assess the prevalence of signal alterations within the paravertebral muscles in dogs with acute thoracolumbar intervertebral disk extrusion. Second, to describe their MRI features and investigate possible associations between the intervertebral disk herniation and neurological findings. Furthermore, we performed a histological examination of the musculature with signal alterations in five dogs to investigate the underlying pathological features.Medical records between August 2014 and June 2016 were reviewed and scrutinized for dogs undergoing MRI of the thoracolumbar spine as a result of acute intervertebral disk disease. Dogs were included in the study if they were presented for MRI within 7 days of the onset of clinical signs. Further inclusion criteria were a neurologic examination and that the MRI examination protocol included a fat-suppressed T2W sequence. Dogs were excluded when the medical history suggested changes in the spinal musculature may have occurred. This could be a consequence of a car accident, a fall from a great height, previous spinal surgery within a period of 1 year or previous injections in the paraspinal region. MRI examination was performed in a 1.0-T open permanent magnet .Duration of clinical symptoms and neurological grade was noted based on clinical records. The neurological grade was classified based on neurologic examination as grade 1 (pain only), grade 2 (ambulatory paraparesis), grade 3 (non-ambulatory paraparesis), grade 4 (paraplegia with no loss of deep pain sensation), or grade 5 (paraplegia with loss of deep pain sensation) .Images were reviewed by a board-certified radiologist (DSG) for the presence of signal alterations within the paravertebral musculature in fat-suppressed T2W sequences, either Short-TI Inversion Recovery sequence or Spectral Presaturation with Inversion Recovery sequence. If muscle signal alterations were present, their anatomical localization was noted based on the affected muscle, the site along the vertebral column, side, laterality , length, and signal intensity in the different sequences as well as contrast enhancement in postcontrast sequences, if available, were assessed.Furthermore, the location and type of intervertebral disk herniation [compressive versus non-compressive intervertebral disk extrusion] was noted. Acute noncompressive nucleus pulposus extrusion (ANNPE) represents an acute extrusion of normal, non-degenerate, nucleus pulposus material, causing minimal to no spinal cord compression. The diagnosis of ANNPE have been made based on established MRI criteria consisting of (i) a focal area of intramedullary spinal cord hyperintensity on T2W images that overlies an intervertebral disk space, (ii) a reduction in volume of the T2W hyperintense nucleus pulposus signal, (iii) mild narrowing of the associated disk space, and (iv) extradural material or signal intensity change with minimal or no spinal cord compression at this level . The locMuscle signal alterations were compared to the location of intervertebral disk extrusion. They were described as being cranial, at the same level or caudal and compared to the location of compressive material in terms of laterality .To investigate possible influencing factors on the prevalence of muscle signal alterations, the association between dogs with and without muscle signal alterations and type of disk extrusion, location of intervertebral disk extrusion, degree of compression, presence of epidural hemorrhage, duration of clinical symptoms in days, and neurological grade was calculated with a Chi-Square test. For factors with low cell frequency (<5) and binary outcome (type of disk extrusion) the Fisher’s exact test was performed. For low cell frequency (<5) and non-binary outcome, the number of categories was reduced to increase the counts in the remaining. Grouping was performed for the parameter “location of disk extrusion” according to the presence or absence of ribs into T3–T13 and L1–L7. The parameter “neurological grade” was grouped into ambulatory dogs (grades 1 and 2) versus non-ambulatory dogs .P < 0.05) with the presence of muscle signal alterations in the univariable analysis were offered to a multivariable logistic regression model. Variables were selected by stepwise backward selection, until only significant variables and confounders (variables changing the effect of other variables by >20%) remained in the model. Model fit was assessed by deviance statistics, chi-square goodness of fit test, and visual assessment of residuals. Statistical analysis was performed in NCSS 10 Statistical Software (2015) . Differences were considered statistically significant if P < 0.05.Factors which were significantly associated , Dachshund (n = 15), Mixed-breed dog (n = 12), Shih Tzu (n = 8), Labrador Retriever (n = 4), Bolonka Swetna (n = 3), Coton de Tuléar (n = 2), Cocker Spaniel (n = 2), Yorkshire Terrier (n = 2), Poodle (n = 2), Schnauzer (n = 2), Basset Hound (n = 2), and one of each of the following American Staffordshire Terrier, Appenzeller Sennenhund, Beagle, Border Collie, Border Terrier, Cane Corso Italiano, Chihuahua, Chinese Crested Dog, German Shepherd Dog, Entlebucher Mountain Dog, Jack Russell Terrier, Lhasa Apso, Maltese Dog, Pug, Papillon, Pekinese, Pinscher, Siberian Husky, Tibetan Spaniel, Tibetan Terrier, and West Highland White Terrier.In total, 103 dogs  met the inclusion criteria. Mean age was 6.3 years (range: 1–13 years). Affected breeds were French Bulldog . The signal intensity was hyperintense on T2W images in 29 dogs, with changes only visible on fat-suppressed sequences in eight dogs (22%)  in 13 dogs (43%), and no enhancement was seen in 17 dogs (57%). T2* sequences were available in all dogs, a signal void in T2* was not detected in any dog.n = 13; 35%) or in multiple paraspinal muscles . Two muscles were affected in 15 dogs (41%), three muscles in four dogs (11%), four muscles in four dogs (11%) and six muscles in one dog (3%). The most commonly affected muscles were Mm. multifidi (n = 15), M. longissimus (n = 14), M. psoas major (n = 11), M. psoas minor (n = 11) and M. iliocostalis (n = 2) (Table In 18 dogs (49%), unilateral signal alterations were observed (nine dogs right and nine dogs left); bilateral alterations were seen in 19 dogs (51%). The observed signal alterations were seen in one muscle , followed by L2/3  as the second most common site. In dogs with muscle signal alterations most intervertebral disk extrusions were present at L2/L3 , followed by L1/L2 and T12/T13  .Intervertebral disk extrusion was most often located at T12/T13  extending to a different degree cranial and/or caudal .Compressive extrusions were present in 91 dogs (88%), whereas 12 dogs (12%) had an ANNPE without compression of the spinal cord. Only one dog demonstrated ANNPE signal alterations within the paraspinal muscles and type of disk extrusion was not associated with muscle signal alterations , between 30 and 40% impingement , between 40 and 50% , or more than 50% . The degree of compression was not associated with the presence of muscle signal alterations. In 13 dogs, muscle signal alterations were ipsilateral to the side of compression and in a single dog on the contralateral side. Despite unilateral compression, the muscle changes were observed bilaterally in 18 dogs. Ventral compression resulted in either unilateral or bilateral muscle signal changes.Dogs presented with varying degrees of spinal cord compression; less than 30% impingement (P = 0.738).Epidural hemorrhage was identified in 44 dogs (43%). Epidural hemorrhage was not associated with muscle signal alterations .In dogs with muscle signal alterations, the median neurological grade was 4, compared to a median of 3 in dogs without signal changes. The proportion of dogs with muscle signal alterations was higher in non-ambulatory dogs  compared to ambulatory dogs   were presented within the first 24 h after the onset of clinical symptoms, the remainder within 48 h , 3 days , 4 days , 5 days , 6 days , or 7 days . Duration of clinical symptoms was not associated with the presence of muscle signal changes.Most dogs (P = 0.03) than dogs with a disk extrusion cranial to L1. Neurological grades 1 and 2 were grouped, and used as the reference group. Grades 3, 4, and 5 were compared to the reference group, respectively. Dogs with a neurological grade of 3, 4, or 5 had a higher risk for muscle signal changes compared to dogs with a grade of 1 or 2 (P = 0.002). The Odds ratios for neurological grades 3, 4, and 5 were 7.3 (95%CI = 1.3–39.1), 12.1 (95% CI = 2.4–60.2) and 10.5 (95%CI = 1.7–62.7), respectively.The two factors significantly associated with the presence of muscle signal changes in the univariable analysis were also significant in the multivariable logistic regression model. Dogs with a disk extrusion caudal to L1 had a higher risk for muscle signal changes (OR = 2.8, 95%CI = 1.1–7.0, Histopathological examination revealed a focal to focally extensive, mild to moderate acute muscle fiber degeneration and necrosis in three samples, characterized by fragmentation of the sarcoplasm. The basal lamina and the endomysium were intact in most cases. Between the degenerated fibers, a mild to moderate accumulation of fibrin, neutrophilic granulocytes and edema was present. In addition, there was extensive hemorrhage in one sample and two muscle samples showed mild edema.Paraspinal muscle signal alteration was observed in 36% of dogs with acute intervertebral disk extrusion and is, therefore, considered a common finding on MRI examination. The MRI pattern of these changes corresponds to a muscle edema. This pattern of T2-hyperintense and T1-iso- to hypointense signal abnormality is an unspecific alteration and the potential underlying causes are diverse. This finding has not been previously described in dogs or humans in association with acute intervertebral disk extrusion. The underlying cause for the signal changes is unknown; therefore muscle samples from the affected musculature were taken prospectively in five dogs to investigate the underlying pathomechanism. The results of the histopathologic examination were rather unspecific with changes including edema and focal muscle necrosis. An explanation for these changes may be trauma, ischemia or denervation, but the exact cause could not be determined by histopathology.Penetration of extruded intervertebral disk material into the musculature may directly induce trauma and the associated signal alterations. However, this seems unlikely since the signal alterations were often observed bilaterally or even contralaterally to the extrusion. Furthermore, lesions were seen caudally or cranially to the extruded intervertebral disk without being in contact to the intervertebral disk space. Muscle signal alterations were observed in the majority of dogs within the epaxial muscles, dorsal to the level of the transverse processes of the vertebrae, but in 12 dogs, signal alterations were observed only in the hypaxial muscles, ventral to the transverse processes. These observations suggest that penetration of extruded intervertebral disk material in to the musculature is unlikely to be responsible for the signal alterations.Both epaxial and hypaxial muscle groups are innervated by the spinal nerves from their dorsal or ventral branches, respectively . Damage If neuronal or axonal damage occurs without inducing Wallerian degeneration of the axons, the changes in the axons are considered to be reversible . OtherwiThe muscle signal alterations were best identified in fat-suppressed T2W sequences, which are used as part of our routine protocol in dogs with acute back pain to identify changes in soft tissues . IdentifIn conclusion, we observed muscle signal alterations within the paraspinal muscles in more than one third of dogs with acute thoracolumbar intervertebral disk disease. The changes occur more frequently in intervertebral disk extrusions caudal to L1 and in dogs with a higher neurological grade. The rather unspecific MRI pattern of the edematous lesions as well as the histological findings obtained from five dogs hinders clarification of the underlying pathomechanism, but denervation edema may explain the signal alteration observed in dogs with acute intervertebral disk extrusion.Consent procedure is not applicable, as this article is a retrospective study of clinical cases.This study was carried out in accordance with the ethic recommendations of the veterinary Office, Kanton Bern, Switzerland.Conception and design: DS-G and PT. Acquisition of data: PT, DH, MW, CG, FF, and DS-G. Analysis and interpretation of data: PT, DS-G, CG, MW. Drafting the Article: PT and DS-G. Revising article for intellectual content: DS-G, PT, and MW. Final approval of the completed article: PT, CG, MW, FF, DH, and DS-G.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In recent years, neurologists are noticing that evaluation of multiple sclerosis (MS) patients based on combining relapses, disability progression, and magnetic resonance imaging activity may be insufficient to adequately assess suboptimal responses to available therapy. Inclusion of quality of life (QoL) parameters may contribute to breach this gap.To evaluate agreement levels between doctor and patient perception of QoL in MS.A total of 700 MS patients and 300 neurologists were invited to participate in a cross-sectional study by answering an e-mail questionnaire. The survey collected information on demographical data and included the Short Form questionnaire (SF-36). After completing the questionnaire, patients were given a standard written description of each of the subdomains assessed by SF-36 and asked to identify which three were the most important determinants of their overall health-related QoL.p < 0.001). Important to note, the results of SF-36 questionnaire were highly correlated with the perception gap between patients and neurologists .A total of 135 neurologists and 380 MS patients responded the survey. Study population mean age was 42.1 ± 10.5 years, with 61% presenting relapsing-remitting MS. SF-36 results were physical function 68.4 ± 30, physical role limitation 56.8 ± 41.7, vitality 47.6 ± 21.4, pain 71.2 ± 26.1, social function 72.6 ± 28.6, emotional role limitation 63.2 ± 39.8, mental health 60 ± 14.1, and general health 55.8 ± 22. Doctors considered physical function (75%) and physical role limitation (70%) as the most important QoL determinants in MS, followed by emotional role limitation (52%). Patients however, assigned significantly different levels of importance to physical function (58%), and physical role limitation (46%) and considered vitality (52%) more important than their physicians (Concerns on QoL in MS are different for patients and physicians. It is essential to enhance communication in order to better understand actual patient needs. Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system leading to demyelination and neurodegeneration. It is the second cause of disability in young adults after car accidents.Quality of life (QoL) assessment has many apparent merits in chronic illness outcome measurement. It can be used to measure incremental improvement rather than complete cure, considering a wide range of aspects of daily living, it is centered around the patient and can be used across various medical disciplines .WHO defines QoL as an individual’s perception of life in the context of the culture and values system they live in, as well as in relation to their goals, expectations, standards and concerns. Some definitions of QoL focus on subjective patient perspective of health status , 3, wherHealth-related QoL (HRQoL) represents the link between QoL and individual health status. It is generally considered to be multidimensional, encompassing physical and occupational function, emotional status, social interaction, and somatic sensations . Thus, HMultiple sclerosis significantly affects QoL, interfering with a patient’s ability to work, pursue leisurely activities, and execute daily life tasks. Although different studies have investigated QoL in MS patients –11, resuTraditionally, physicians have singled out physical and emotional symptoms as the most important negative aspects of illness, equating health to absence or reduction of disease, and not to complete physical, mental, and social well-being . Indeed,In fact, in recent years, researchers are recommending evaluation of HRQoL be included in the definition of No Evidence of Disease Activity .In this study, we analyzed different factors affecting HRQoL in a cohort of Argentine MS patients. Additionally, we assessed differences between patient and doctor perception of HRQoL in MS.We designed a cross-sectional study implemented through an e-mail questionnaire sent out to 700 patients from the Institute for Neurological Research Dr. Raúl Carrea in Buenos Aires, Argentina and from an Argentine MS patients association (ALCEM), member of the MS International Federation between February and March 2016. The study was prepared following Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement guidelines for cross-sectional studies .Patients were eligible if they fulfilled 2010 Mc Donald Criteria  and had The survey was specifically designed to study demographical data and medical aspects of disease. Questions included information on: MS type, disease duration, walking ability, and use of disease-modifying therapies.Finally, patients answered the Short Form questionnaire (SF-36), a HRQoL instrument which has been used extensively to quantify HRQoL changes in MS patients , 16, 17 Invitations to participate in the study were sent out to all members of the Argentinean Society of Neurology through their weekly online newsletter. The society has 1,200 active members and viewing rates for the newsletter average 25%. Of the approximately 300 neurologists who read the survey, 135 agreed to participate. Physicians were asked to select which three of all SF-36 domains were the most important determinants of patient HRQoL. Physician demographics were also assessed .Study protocol was approved by the Institutional Ethics Committee, and written informed consent obtained from all participants before entering the study.Z-test at a confidence level of 90% with a one-tail test of significance. All analyses were performed using software package SPSS for Windows (version 20).Descriptive statistics was used to summarize baseline patient demographics and MS clinical status. Data of the three most important SF-36 domains were expressed as the proportion of patients and neurologists who identified a domain as one of the three most important. All statistical analyses included the A total of 380 individuals with MS and 135 neurologists answered the questionnaire.n = 34).Because a recent relapse could transiently modify HRQoL perception, patients experiencing exacerbations during the previous month were excluded from the analysis  reported a positive view , a result associated with younger patient age, recent diagnosis (in the last year), female gender, and better walking performance. Older age was associated with worse outcomes for all SF-36 domains, except mental health (p < 0.04). Unrestricted walking was associated with better SF-36 results (p < 0.01). No differences were observed in patient walking scores prior to becoming restricted to a wheelchair. Almost 60% of patients reported limitations when carrying out intense activities such as running, lifting heavy weights or practicing high performance sports; and 50% had reduced their daily work activities (ADL). 90% of patients referred fatigue, constant, or during most of the day for 61 and 50% referred exhaustion during the last month.Mean scores of each SF-36 domains are shown in Figure p = 0.14; IFN vs. glatiramer acetate (GA) p = 0.59; IFN vs. oral therapies (OTs) including teriflunomide or fingolimod p = 0.09; NZB vs. GA p = 0.1; NZB vs. OT p = 0.68; GA vs. OT p = 0.11].These results were not related to current disease modifying treatments [interferons (IFNs) vs. natalizumab (NZB) Doctors considered physical function (75%) and physical role limitation (70%) as the most important determinants of overall HRQoL in MS, followed by emotional role limitation (52%). We found physician answers were not affected by gender, work-place, or years of specialty experience.p < 0.001). Patients also considered vitality (52%), general health (30%) and presence of body pain (30%) important, all aspects not considered as relevant by the majority of neurologists .Although patients also considered physical function (58%) and role limitation (46%) to be important aspects of their HRQoL, results were significantly different from those reported by neurologists .Important to note, the results of SF-36 questionnaire were highly correlated with the perception gap between patients and neurologists (p < 0.001).When scores were analyzed according to patient mobility, we found that fully ambulatory patients referred vitality, mental health and physical function (in that order) as the most important aspects influencing HRQoL; whereas patients with minimal disability  singled out physical function, physical role limitation followed by vitality as the most relevant subdomains  and biological (atrophy and neurofilament levels) when evaluating suboptimal response to MS treatment . In factIn this study, we found disagreement between MS patients and treating physicians regarding factors affecting HRQoL. While clinicians focused mainly on physical aspects, patients considered vitality, pain, as well as general, emotional, and mental health also relevant.Nevertheless, in comparison to previous studies , 11 we fFurthermore, comparison between the present study and other published series  such as As expected, SF 36 results in this study were better in fully ambulatory patients . PredictAs mentioned, most subjects referred fatigue as a limitation to activities of daily living. Mechanisms underlying fatigue in MS are unknown nor have potential links to current treatments been ruled out –28. BecaOf note, classical trials evaluating treatment efficacy increasingly incorporate patient-reported outcomes (PROs) to support labeling claims. A PROs is any report regarding patient health status referred directly by patients, without clinician or third party interpretation. Although linked, HRQoL and PRO should not be used as interchangeable terms. PROs address the source of the report, not the concept or content, and therefore represent disease effects on health and functioning from the patients’ perspective. Quite often, as we observed in this survey, patient, and doctor perspectives do not coincide . In an aWe recognize the present study has limitations. First, neurologists from the SNA were invited to participate through a newsletter. Although newsletters in general have rather low online viewing rates , it alloBeyond these limitations, QoL data collected in this study are a clear example of the disagreement between MS patients and physicians in terms of assessment, and reinforce the need to enhance neurologist/patient communication. New tools like PROs are being increasingly implemented and may help us better understand real patient needs. The data reported in this article suggest moreover, that we are starting to head in the right direction.This study was carried out in accordance with the recommendations of “Institute Raúl Carrea, Institutional Review Board” with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the “Institute Raúl Carrea, Institutional Review Board.”MY and MF contributed to the conception and design of the work. MY, MF, and MG made the acquisition of the data. MY, MF, and JC contributed to the interpretation of the data and statistical analysis. MY and JC wrote the manuscript. All authors revised the draft of the manuscript and provided important intellectual contributions.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sexually transmitted infections (STIs) remain an important public health problem with approximately half a billion new cases annually among persons aged 15–49 years. Epidemiological data on STIs among women of reproductive age in Swaziland are limited. The availability of epidemiological data on STIs and associated risk factors in this population is essential for the development of successful prevention, diagnosis and management strategies in the country. The study aimed to determine the prevalence and risk factors associated with STIs.Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), GeneXpertTV Assay for Trichomonas vaginalis (TV), and GeneXpert HPV Assays for hr-HPV. Blood samples were tested using Alere Determine HIV-1/2Ag/Ab Combo and Trinity Biotech Uni-Gold Recombigen HIV test for confirmation for HIV, and Rapid Plasma Reagin and TPHA test for confirmation for Treponema pallidum (syphilis). Genital warts were assessed prior to specimen collection. Survey weighted analyses were done to estimate the population burden of STIs.A total of 655 women aged 15–49 years were systematically enrolled from five health facilities using a cross-sectional study design. Cervical specimen were tested using GeneXpert CT/NG Assays for Treponema pallidum (syphilis), as well as genital warts were considered in this study. The overall weighted prevalence of any of these five STIs was 19.4% (95% CI: 14.9–24.8), corresponding to 72 990 women with STIs in Swaziland. The estimated prevalences were 7.0% (95% CI: 4.1–11.2) for CT, 6.0% (95% CI: 3.8–8.8) for NG, 8.4% (95% CI: 5.4–12.8) for TV, 1.4% (95% CI: 1.1–10.2) for syphilis and 2.0% (95% CI: 1.0–11.4) for genital warts. The overall weighted HIV prevalence was 42.7% (95%CI: 35.7–46.2). Among hr-HPV positive women, 18.8% (95% CI: 13.1–26.3) had one STI, while 6.3% (95% CI: 3.3–11.7) had multiple STIs. Risk factors associated with STIs were being employed , self-employed  and being hr-HPV positive . Age , being married  and not using condoms with regular partners  were inversely associated with STIs.The four most common curable STIs: CT, NG, TV, STIs are highly prevalent among women of reproductive age in Swaziland. Thus, a comprehensive STIs screening, surveillance and treatment programme would be justified and could potentially lower the burden of STIs in the country. Chlamydia trachomatis (CT), 78 million are from Neisseria gonorrhea (NG), 5.6 million are from syphilis and 143 million are from Trichomonas vaginalis (TV) cases [Globally, sexually transmitted infections (STIs) remain a significant public health problem mainly in low-income countries , 2. CurrDepending on which STI and the population, in low-income countries largely in SSA, NG, CT, TV, Human papillomavirus (HPV), herpes, and syphilis increase the risk of HIV acquisition and transmission between two to eight fold , 6–9. FuFactors affecting the spread of STIs, including HIV, have been documented in many epidemiological studies across different populations –24. STIsThere is limited information on the prevalence and risk factors associated with STIs at population level in Swaziland, the country which has the highest prevalence of HIV infection worldwide. The availability of epidemiological data on STIs and associated risk factors in this population is essential for the development of successful prevention, diagnosis and management strategies in the country . This stThe study participants were women aged 15–49 years attending five healthcare facilities for routine healthcare and related services such as family planning, vaccination etc., from June to July 2015. This cross-sectional study included all women of reproductive age with a history of or who are currently sexually active and who provided written informed consent. The health care facilities  hospital, Hlatsikhulu hospital, Sithobela hospital and Siteki Public Health Unit) were located within the four political regions of Swaziland as shown in Table The sample size determination was based on the main research project aim, namely of establishing the burden of HPV infection and HPV-related conditions among women of reproductive age in Swaziland, where the value of the parameter(s) were not known in Swaziland. The prevalence of STIs investigated in the study was a secondary objective. Hence, the use of 50%, which assumes maximum variability and the largest possible sample size, given the predefined precision of ±5% and 95% confidence (5% type I error). Based on this a, sample size of 384 subjects was required to be used. The sample was further increased by a margin of 10% to account for potential non-response and multiplied by a design effect (D) of 1.5. The final calculated sample size of the study was 650 women. However, a total of 655 women participated to the study.The recruitment of participants was done in two sampling stages. Firstly, women were stratified by age (seven age-groups) and then sampled in each site using systematic random sampling (every third woman of each age), using the lottery method. The participants were selected from each site until the calculated sample size was achieved per site.Prior to questionnaire administration, willing participants were given all the necessary information about the study, their potential contribution, and their risks and benefits before they signed the informed consent form. Furthermore, all necessary information was included in the study information sheet and informed consent documents. A structured standardized questionnaire was administered by trained nurses to obtain detailed data on socio-demographic characteristics, and sexual, reproductive and gynaecologic histories. Thereafter, the nurse midwife inspected the perineal, vulvar, vaginal and cervical regions of each woman for evidence of genital warts, ulcers, discharge, inflammation or tenderness, and recorded all abnormalities according to the study protocol. Lastly, the specimen collection for each of the tests was performed (see details below). All participants found to be exhibiting genital warts were treated with the WHO-recommended 0.5% podophyllin tincture. Additionally, all participants presenting with STIs on syndromic diagnosis or/and who tested positive for STIs, were treatment as per WHO STIs management guidelines , which hData were entered using EpiData 3.02 for Windows . Each participant was assigned a unique study identity number that was used to link the questionnaire and the biological specimens. Personal information was blinded from the researcher and was kept on site for feedback of the results to the women, and validation of data.After visual inspection of the vulva, a non-lubricated sterile disposable speculum was inserted and cervical cells were collected using the Xpert CT/NG/TV Endocervical swab (CT/NG/TV SWAB-50) . After HIV pre-counselling, two 4 mL samples of blood (for HIV and syphilis testing) were collected in a vacutainer tube from participants consenting to HIV testing. All specimens were collected and transported daily to the National Referral Laboratory (NRL).All specimens testing were tested at the NRL, Mbabane, Swaziland. Since this work is part of the HPV/Cervical cancer study, only overall weighted HPV and HIV prevalence results are presented in this paper, for a purpose of assessing the association between the curable STIs and HPV and HIV.Chlamydia trachomatis (CT) and Neisseria gonorrhea (NG) infection, and the Cepheid Xpert TV Assay was used to detect Trichomonas vaginalis (TV)  [Cepheid Xpert CT/NG assay was used to detect A, 2014) , 31. AllTreponema pallidum (Syphilis) testing was routinely conducted on all participants who consented to HIV testing using a commercially available standard Rapid Plasma Reagin (RPR) test  [Treponema pallidum Hemagglutination Assay (TPHA)  [dge, UK) , followiand, UK) .The HPV-DNA testing was done using the GeneXpert HPV assay (Xpert HPV Assay)   accordinThe Alere Determine HIV-1/2 Ag/Ab Combo test was used to detect both HIV-1/2 antibodies and free HIV-1 p24 antigen . ReactivData were processed and analysed using Stata 13.0SE . Data were checked for possible errors and missing values prior to analysis. Age and region-weighted analyses were done to estimate the overall STIs’ prevalence and coinfection with HIV and hr-HPV.χ2) test. Odds ratios (unadjusted and adjusted) and 95% CIs for potential risk factors associated with STIs were estimated using survey weighted logistic regression models. Variables that were significant at a cut-off of 0.2 in the bivariate regression analyses were selected for inclusion into the final multivariable model. An adjusted p-value of <0.05 was deemed statistically significant.Survey weighted analysis was done to adjust the sample characteristic to match the target population (15–49) that they were selected to represent. It is applied to bring the proportion of women in the sample in alignment with the portion of women in the target population. Therefore, all results are reported as weighted. Survey weighted prevalence and 95% confidence intervals (CI) were calculated. In addition, assuming that our study subjects were representative of the female population of the same age strata, we used survey weights to extrapolate sample proportions to population totals (age-region weighted) to estimate burden counts, based on the 2007–2030 population projections aligned to the estimated 2014 population of 377 169 women aged 15–49 years [A total of 655 women were enrolled in the study within the period of June - July 2015. All the participants had sufficient specimens for the four non-viral STIs testing and only 11 had sufficient specimen for hr-HPV. Table Trichomonas vaginalis (TV), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Treponema pallidum (syphilis) and genital warts (GW) was 8.46.0, 7.0, 1.4 and 2.0%, respectively. The overall weighted hr-HPV prevalence and HIV prevalence was 46.2% (95% CI: 42.8–49.5), and 42.7% (95% CI: 35.7–46.2) respectively, , and 6111 (95% CI: 470–12692) have GW. Multiple STIs estimates were 13995 (95% CI: 7 092–20 898) and triple STIs were 23 310 (95% CI: 14 193–32 427). Among HIV positive women, the population burden counts for single STIs were 32 158 (95% CI: 20 200–44 115) and for multiple infection 10 798 (95% CI: 4 032–17 564). Among hr-HPV positive women the population burden counts for single and multiple infection were 27 163 (95% CI: 14 941–39 386) and 6 367 (95% CI: 159–12 893), respectively) (Table Tables  95% CI: 70–12692 p = 0.32), NG was higher among 20–24 years old  while TV was higher among 25–29 years old  as compared to all ages (data not shown).Table p = 0.001). Women with secondary/high school education had a prevalence of 22.2% as compared to women who had never been to school (9.1%). Unemployed and self-employed women had a prevalence of 21.6, and 21.8% respectively as compared to employed women (14.7%). There was no statistically significant difference between women who reported being pregnant before as compared to women who had never been pregnant .The prevalence of STIs was significantly higher among single women (26.4%) as compared to married women (11.2%) (p < 0.001), the number of sexual partners (p < 0.001) and contraceptive use by age group (p < 0.001) was observed. Having two and three sexual life-time partners was associated with an increased risk OR = 5.1 (95% CI: 1.2–21.5) and OR = 8.4, (95% CI: 1.3–54.2) respectively for STIs. Being hr-HPV positive was significantly associated with increased risk of STIs . In the final logistic regression model , factors independently associated with increased risk of STIs were: being employed , self-employed  and hr-HPV positive status . Being married, mean age and not using a condom one’s with regular partner were found to be inversely associated in the final model  respectively, as compared to not having a sexual life partner.Based on the univariate analysis: the mean age, being married, increasing number of pregnancies and not using condoms with ones’ regular partner were inversely associated with STIs’ risk. Significant differences in proportions regarding those married (p = 0.001) but there was a significant positive association between HIV and syphilis (p = 0.001). There was a significant positive association between hr-HPV and NG and CT (p = 0.020 and p = 0.001). A significant association with TV and hr-HPV (p = 0.058) was observed (results not shown).Individual STI association with HIV and hr-HPV was assessed. There was a significant inverse association between HIV and CT (p = 0.001). A proportion of the women had triple co-infection (6.3%), interact either directly with one another or indirectly via the host’s resources or immune system. Studies have demonstrated that, as compared to infections of single pathogen species, these interactions within coinfected hosts can alter the transmission, clinical progression and control of multiple infectious diseases [The current study in Swaziland shows a high prevalence of STIs (19.4%), corresponding to 72 990 women of reproductive age with STIs. Our data suggests that TV was the most prevalent curable STI (8.4%) among those examined in this study. Furthermore, the prevalence of HIV remains significantly high (42.7%) in this population. The prevalence of the STIs decreased with increasing age however, differences by age groups were not statistically significant. A high percentage of women infected with hr-HPV had one STI (18.8%), while 6.3% had multiple STIs. Single women were at higher risk of being infected with STIs compared to married women , and the prevalence was 1.9% while 4.7% showed a history of syphilis infection by RPR results [The high prevalence of STIs (19.4%) in this population indicates that STIs are a serious public health problem in Swaziland. Our findings were consistent with previous studies from similar populations across the Southern African Development Community region (SADC) and other sub-Saharan regions , 41–43.  results . A compa results , 49. AltHIV remains one of the major public health challenges in Swaziland, with the highest prevalence among women of reproductive age , 51. ThiThe observed high prevalence of STIs in the younger age groups as compared to the older age groups in our study is consistent with other studies , 52, 53.In this current study, single women and women living with partners (but not married) had the highest prevalence of STIs. Similar evidence has been found in other studies , 55. In As far as education is concerned, our findings have shown that women with a lower level of education are most likely to have an STI. Studies have shown that women with less education have an increased risk of STIs , 57, 58.In this study, the risk associated with STIs among women with two or more sexual life-time partners was five to eight times higher as compared to women with no sexual partners in the univariate analysis. Our findings were consistent with other studies which reported that sexual activity with many partners increases the odds of STIs , 54. HowInconsistent condom use as a risk factor for STIs in women has been demonstrated in other studies , 62. In HIV positive status was not associated with STIs in both analyses but when assessed by individual STIs, a significant inverse association between HIV and CT, and significant positive association between HIV and syphilis were observed. No statistically significant association between HIV and NG or TV was observed in the current study. However, studies have indicated that depending on the STI involved and the population, NG, CT, TV, HPV and syphilis increase the risk of HIV acquisition and transmission from two to eight times or more , 6, 7. FA vital clinical and public health consequence of our findings is that hr-HPV was the most significant risk factor associated with STIs infection in both univariate and multivariate analysis (unadj-OR = 2.1 and Adj-OR = 2.0). When assessing the association between hr-HPV and individual STIs, there was a significant positive association between hr-HPV and NG and CT. The strong association between HPV infection and STIs has been demonstrated in previous studies, where infection with hr-HPV types, was a risk factor for CT and NG infection –66. ThesThe curable STIs , and HIV and HPV are sexually transmitted infections, which share the same transmission route and behavioural risk factors. If the curable STIs are not treated, they can lead to a variety of different health risks and greatly increase HIV/HPV transmission risk with further chronic health implications. Collectively, our data have shown the significantly high prevalence of and association between STIs and HIV/HPV coinfection, which tends to subscribe to the new concept in which HIV and HPV infections may be bi-directional, each increasing the risk of the other –69 STIs In conclusion, although STIs may be treated and are curable, they remain a major public health challenge in Swaziland where HIV infection is highly prevalent. Our study indicates that there is a need for a comprehensive STI screening, surveillance and treatment programme in the country.