Trichuris trichiura (whipworm) infection; higher vegetable consumption was associated with lower systolic BP. Results for diastolic BP were similar, except higher fruit, rather than higher vegetable consumption was associated with lower diastolic BP and there was no association with waist circumference or Trichuris trichiura infection. In summary, life-course exposures were associated with adolescent BP in this tropical birth cohort. Malaria early in life could impact later BP. Interventions initiated early in life targeting individuals with family history of hypertension, aiming to reduce adiposity (in pregnancy and adolescence) and promoting fruit and vegetable consumption might contribute to reducing the risk of high BP and subsequent cardiovascular diseases.We aimed to investigate life-course factors associated with blood pressure (BP) among Ugandan adolescents. Between 9th April 2003 and 24th November 2005, 2507 pregnant women from Entebbe municipality and Katabi sub-county were enrolled into a deworming trial. The resulting 2345 live-born offspring were followed to age 10 or 11 years, when between 20th May 2014 to 16th June 2016, BP was measured following standard protocols. Factors associated with BP were assessed using multivariable linear regression. BP was measured in 1119 adolescents with a median age of 10.2 years. Mean systolic BP and diastolic BP was 105.9 mmHg (standard deviation (SD) 8.2) and 65.2 mmHg (SD 7.3), respectively. Maternal gestational body mass index (BMI), higher maternal education status and family history of hypertension were positively associated with adolescent BP. Childhood (age ≤5 years) malaria was associated with lower adolescent systolic BP. Factors measured at time of BP measurement positively associated with systolic BP were age, BMI, waist circumference and  Once uncommon in Africa , high blAlthough high BP is less common in children and adolescents than in adults, it initiates early in life, persists into adulthood  and predSevere persistent high BP is associated with increased risk of stroke and heart failure ; treatmeEarlier studies, mainly in adults, have demonstrated the role of established risk factors for high BP such as obesity  and physChildhood and adolescence are opportune periods for high BP control or prevention before clinical manifestation of hypertension or related CVDs. Identification of life-course BP risk factors unique to Africa is needed for the development of appropriate BP control strategies. We used longitudinally collected data from the Entebbe Mother and Baby Study (EMaBS), a large tropical birth cohort, to describe factors associated with adolescent BP.This longitudinal observational study investigated perinatal and life-course factors associated with BP among adolescents born in Wakiso district, Uganda. The EMaBS was a randomised double-blind placebo-controlled factorial trial [ISRCTN32849447], designed to investigate effects of worms and their treatment in pregnancy and childhood on response to childhood vaccines and on infections .The study was conducted in Entebbe municipality and Katabi sub-county (a peninsula on the northern shores of Lake Victoria). In 2003–2005, 2507 women attending Entebbe Hospital antenatal clinic, in their second or third trimester were invited, enrolled and randomised to receive albendazole (400 mg) or placebo and praziquantel (40 mg/kg) or placebo .Data were collected prenatally from women and resulting 2345 live-born offspring followed from birth. As previously described , at 15 m2). Trained clinicians examined and performed Tanner staging as described elsewhere . Briefly, participants stood barefooted on the posterior electrode base while holding two anterior electrodes handles of the SBCAM. Fat mass index = FMI (kg)/height  ova and Strongyloides larvae using Kato-Katz [Mansonella perstans. Maternal HIV status at enrolment and children’s HIV status after 18 months of age were assessed using a rapid serial testing algorithm described elsewhere [Stool and blood samples were collected from women at enrolment and annually from children. Stool was examined for helminth  were taken after 5 min rest using automated devices (Omron M6), with appropriate sized cuffs .For clinical care purposes, means of the three systolic BP and three diastolic BP measurements were calculated and BP percentiles determined using Centre for Disease Control height charts and 2004 updated National Health and Nutrition Examination Survey BP tables specific for sex, age and height , 10. ThoFor data analysis purposes, the means of the second and third systolic/diastolic BP readings on day 1 were used: day 1 second and third BP readings were lower than the first BP reading but similar to each other .Ethical approval was granted by the Uganda Virus Research Institute Science and Ethics Committee; the Uganda National Council for Science and Technology; and the London School of Hygiene and Tropical Medicine. Written informed assent and consent were obtained for study participation.t-tests (for continuous variables) were used to compare characteristics of cohort members who participated and did not participate in the BP study.Data were collected on pre-coded questionnaires and analysed with Stata 14.2 . Chi-squared tests  and Study outcomes were mean systolic BP and mean diastolic BP, based on the second and third day-one measurements. The decision was made to model these two continuous BP outcome variables rather than to dichotomise outcomes  as an analysis using these binary outcomes would be underpowered. Maternal, perinatal and offspring life-course factors considered as exposures and potential confounders were: maternal and adolescent socio-demographic and anthropometric characteristics; EMaBS trial interventions ; sickle-cell trait; illnesses and infections from birth to time of BP measurement; and body composition, puberty stage, diet, sleep pattern and physical activity at time of BP measurement. Area of residence was grouped into urban versus rural area using zones based on topography and settlements generated from geographical positioning system data . HousehoLinear regression analysis was used. Data satisfied the assumptions for linear regression. Crude associations were examined for each covariate and a 20% significance level was used for selecting covariates for multivariable models. Adolescents’ sex, age and BMI were confounders a priori. Multivariable analysis followed a hierarchical causal approach adding factors sequentially Fig. .Fig. 1CoBecause of a large proportion of missing data, puberty and body composition variables were not included in model building for other exposures but their effects were each adjusted for variables included in the final multivariable model. Multicollinearity was assessed by considering the change in standard error, when potentially multicollinear variables were included in the same model.A total of 1119 EMaBS participants were enrolled into the BP study: 583 (52%) were males; 1100 (98.3%) singletons; 18 (2%) HIV positive; and 344 (31%) mixed feeding by 6 weeks. EMaBS adolescents participating in the BP study were similar to non-participants, except that mothers of participants were more likely to be of higher education status or married/cohabiting; offspring were less likely to be HIV positive or of a multiple birth, details published earlier .2 (standard deviation (SD) 1.9) and mean waist circumference 58.1 cm (SD 4.9). Body composition data were available for 176 (16%) participants, with mean fat mass index 2.9 kg/m2 (SD 1.2), fat-free mass index 12.8 kg/m2 (SD 1.4) and total body water mass index 9.5 kg/m2 (SD 0.9).At age 10/11 (median participant age 10.2 years (interquartile range (IQR): 10.0–10.9)), 117 (11%) were attending boarding schools, 441 (72%) were pre-pubertal stage for pubic hair development and 178 (65%) of girls were pre-pubertal stage for breast development. Mean BMI was 15.8 kg/mOver the previous month, starchy staple foods, animal proteins, fruit, vegetables and sugar drinks were consumed on average for 6.9 days/week (SD 0.8), 2.2 days/week (SD 1.7), 3 days/week (SD 2.2), 3.4 days/week (SD 2.3) and 1.7 days/week (SD 2.1), respectively. Nearly all adolescents (98%) reported adding salt to cooked food.P-value = 0.971) or diastolic BP  between males and females. None of the adolescents had had a prior BP measurement or high BP diagnosis.Mean systolic BP was 105.9 mmHg (SD 8.2) and mean diastolic BP was 65.2 mmHg (SD 7.3). There was no difference in mean systolic BP  and 42 (7.2%), respectively, among males, and 54 (10.1%) and 52 (9.7%), respectively, among females. After extra measurements on the second and third visits and taking loss to follow-up into account, pre-hypertension prevalence was estimated as 2.2% in males and 0.7% in females; high BP prevalence was 0.4% in males and 1.8% in females.Tables β = 1.84  after adjustment for maternal and childhood factors. Body composition and puberty stage covariates were no longer associated with systolic BP on adjusting for adolescents’ age, BMI and waist circumference.Characteristics at the time of BP measurement showing a crude positive association with systolic BP were age, BMI, waist circumference, family history of high BP, body composition variables and puberty stage covariates. In multivariable analysis, systolic BP increased, on average, by 1.35 mmHg, 95% CI  for each 1-year increase in adolescents’ age; by 0.78 mmHg  per unit increase in BMI; and by 0.21 mmHg  per centimetre increase in waist circumference. Family history of high BP remained associated with increased systolic BP, Lifestyle factors crudely associated with increased systolic BP were increased animal-protein consumption, increased consumption of sugared drinks and attending a boarding school rather than a day school. Increased fruit and vegetable consumption were associated with reduced systolic BP. After adjusting for confounders, systolic BP reduced on average by 1.13 mmHg  among adolescents who consumed vegetables for 3–7 days/week (versus 0–2 days/week).Trichuris trichiura was positively associated with systolic BP after adjusting for confounders ). Systolic BP dropped by 1.24 mmHg  among adolescents who had malaria in childhood compared to those who had not. Both clinical and asymptomatic malaria were independently associated with lower BP in multivariable analysis. Weight and height at 10 and 11 years of age were reduced among adolescents with childhood clinical and or asymptomatic malaria . Systoβ = −0.28 mmHg ), even after adjusting for age and sex. HbAS was inversely associated with malaria .Genetic data were available for 802 (72%) participants of whom 141 (18%) had sickle-cell trait (HbAS) and 661 (82%) normal haemoglobin (HbAA). Sickle-cell trait was not associated with systolic BP  on adolescent BP and no associations between prior helminth infection (in pregnancy or childhood) and adolescent BP.Our findings are consistent with several earlier studies , 26. We Malaria parasitaemia in childhood was associated with lower BP in early adolescence, consistent with findings from a cross-sectional study among 5–18-year-old Ugandan students, which reported that current asymptomatic malaria was associated with lower BP . Our stuSub-microscopic malaria was most likely misclassified as negative in this population, since in malaria-endemic areas, asymptomatic malaria often presents as sub-microscopic in individuals with past malaria infection . We founSimilar to earlier studies , 31, chiTrichuris trichiura  was associated with increased systolic BP in early adolescence. To our knowledge, no study has previously reported such an association. This may reflect short-term effects  or it could be a spurious finding due to the many exposures included in the analysis. The effect of current Trichuris trichiura infection on BP is likely not mediated through increasing BMI (weight or height); there was no difference in these measures between adolescents with and without current Trichuris trichiura infection.Current but not previous infection with Unlike previous studies , we founPrevious studies have linked hypertension to socioeconomic determinants (socioeconomic status (SES), education, income, urbanisation) , 36. OurStrengths of this study included its longitudinal design with prospectively collected data reducing recall and reporter bias, the use of robust BP procedures and the measurement of BP on up to two extra occasions in those with BP ≥95th percentile at the initial visit, to avoid overestimation of high BP. It is unlikely that white-coat phenomenon was an issue as participants regularly attend this clinic for scheduled and/or illness visits. The use of digital machines reduced differences in BP reading between operators which can occur with auscultation.Study limitations include the possibility of residual confounding by unmeasured factors (such as glomerular filtration rate (GFR)). The GFR could not be estimated as creatinine was only measured for a subgroup of the participants. The use of digital BP machines may overestimate BP; however, digital devices used in this study were calibrated twice annually. A large number of statistical tests were undertaken; thus, some findings may be due to multiplicity. However, it is reassuring that most findings are consistent with previous literature, albeit from different settings. Not inviting all adolescents  for up to two extra BP measurements might have resulted in an underestimation in the overall prevalence of pre-hypertension and hypertension. We modelled BP as a continuous outcome, since analysing high or pre-hypertensive BP versus normal BP as a binary outcome (or outcomes) would be underpowered, consequently our findings may not necessarily reflect associations with hypertensive disease.In summary, routine BP screening which is seldom conducted for adolescents at health care visits remains vital in the control and prevention of CVDs later in life. Similar life-course factors to those observed in high-income settings (such as adiposity and diet) affect both systolic BP and diastolic BP among African adolescents. Interventions during pregnancy, childhood and early adolescence could be vital in the control and prevention of later high BP. Multiple intervention strategies initiated during pregnancy and the early postnatal period and continued across a lifetime could be fundamental in the control of adulthood hypertension and CVDs.High blood pressure and cardiovascular diseases are increasing in Africa.Scarcity of data on blood pressure risk factors among African children and adolescents.The risk factors for high blood pressure may differ from those seen in high-income non-tropical settings.Malaria infection in childhood is associated with reduced blood pressure among adolescents. Effects of childhood malaria on later blood pressure may be partially mediated through chronic reduction in weight and height.Trichuris trichiura is associated with increased blood pressure.Current infection with Interventions during pregnancy, childhood and early adolescence could be vital in the prevention of high blood pressure later in life.Supplementary tables


Arbuscular mycorrhizal fungi (AMF) are the most prominent mycobionts of plants in the tropics, yet little is known about their diversity, species compositions and factors driving AMF distribution patterns. To investigate whether elevation and associated vegetation type affect species composition, we sampled 646 mycorrhizal samples in locations between 1000 and 4000 m above sea level (masl) in the South of Ecuador. We estimated diversity, distribution and species compositions of AMF by cloning and Sanger sequencing the 18S rDNA (the section between AML1 and AML2) and subsequent derivation of fungal OTUs based on 99% sequence similarity. In addition, we analyzed the phylogenetic structure of the sites by computing the mean pairwise distance (MPD) and the mean nearest taxon difference (MNTD) for each elevation level. It revealed that AMF species compositions at 1000 and 2000 masl differ from 3000 and 4000 masl. Lower elevations (1000 and 2000 masl) were dominated by members of Glomeraceae, whereas Acaulosporaceae were more abundant in higher elevations (3000 and 4000 masl). Ordination of OTUs with respect to study sites revealed a correlation to elevation with a continuous turnover of species from lower to higher elevations. Most of the abundant OTUs are not endemic to South Ecuador. We also found a high proportion of rare OTUs at all elevations: 79–85% of OTUs occurred in less than 5% of the samples. Phylogenetic community analysis indicated clustering and evenness for most elevation levels indicating that both, stochastic processes and habitat filtering are driving factors of AMF community compositions. Arbuscular mycorrhizal fungi (AMF) are the most prominent mycobionts of plants in the Neotropics , 2. Arbuet al. [et al. [et al. [et al. [et al. [Most of the studies on the effect of elevation on AMF were done in alpine grasslands –17. AMF et al. , Gai et  [et al. and Kotil [et al.  elevatio [et al.  found loet al. [et al. [et al. [et al. [et al. [et al. [et al. [Glomus and Acaulospora spores were the dominant morphotypes of all 58 identified AMF spore types, and Glomeraceae the only family found in all fourteen sequence groups [et al. [et al. [In neotropical forests, studies were done by Geml et al. , Bonfim  [et al. , Looby e [et al.  and Came [et al. . In the  [et al.  studied  [et al.  found a  [et al. , who stu [et al.  found the groups . In Cost [et al.  studied  [et al.  conducte [et al. .Polylepis forest (≈4000 masl). In this area, there is not only a pronounced turnover of tree species and families but also changes in structural features of the forest canopy [These four studies provided a first insight into AMF communities of neotropical forests but were conducted with different methods and revealed different results. There is a large range of AMF species/OTU counts among these studies. Next generation sequencing reveals OTU counts that are much higher than those yielded by morphotyping or Sanger sequencing with cloning. However, all these studies indicate that Glomeraceae are dominating. In order to better understand how neotropical AMF community structure is driven across elevation belts, more research is needed. Here we present results from our studies of AMF communities in the tropical Andes of Southern Ecuador. The Southern Ecuadorian Andes are a promising and suitable research area because they have a breadth of vegetation types, show a broad elevation range and are among the world’s hotspots of biodiversity . This mat canopy , 23, 24.t canopy . HoweverPolylepis forest and grass páramo can be found at the 4000 m sites. Details are summarized in Samples were taken at four elevation belts in Southern Ecuador: 1000 masl, 2000 masl, 3000 masl and 4000 masl , Table 1At each elevation belt, we sampled three to four sites . We collIn total, we successfully worked with 646 root samples: 211 at 1000 masl, 184 at 2000 masl, 128 at 3000 masl, and 123 at 4000 masl . Total DNA was isolated with the innuPREP Plant DNA Kit  and re-suspended in a final volume of 100 μl of elution buffer.Part of the SSU region of the nuclear ribosomal rDNA repeat was amplified by PCR using a volume of 0.5 μl of the DNA template. A nested PCR approach was applied, amplifying the larger outer fragment with the primer combination NS1/NS4 , 34 and Sequences were edited with Sequencher , and a BLAST search was performed against the nucleotide sequence database (NCBI) and against the MaarjAM database. When several inserts of a cloned PCR product belonged to the same OTU, only one sequence was included in the final data set.The final dataset  Tables chttps://mafft.cbrc.jp/alignment/server/, [All sequences were ~800 bp long and comprised part of the 18S. Sequences were aligned with MAFFT version 7  were defined as surrogates for species based on sequence similarity with OPTSIL . We usedpora see .EstimateS 9.1.0 [For all remaining OTUs, we calculated a sample-based rarefaction accumulation curve with 95% confidence intervals, estimated the total OTU richness with Chao2 and Jackknife2 and calculated similarity indices using the software eS 9.1.0 .https://www.rdocumentation.org/packages/vegan/versions/2.4-2/topics/metaMDS). We used a maximum number of 1000 iterations in a 3-dimensional space.To explore differences in AMF community compositions among sampling sites, we carried out a non-metric multidimensional scaling (NMDS) ordination with metaMDS from the R package VEGAN . Our datIn addition, we performed PERMANOVA with the same distance matrix as for the NMDS ordination using elevation levels as variable. PERMANOVA was carried out with the ADONIS function in VEGAN  and 999 We also ran pairwise PERMANOVA  to test for OTU similarity between each site using Holm’s correction to control for multiple comparisons.To check for potential sampling errors, we tested whether OTU similarity is significantly correlated with sample size using a ranked mantel test with the Spearman method in VEGAN . We chosThe same alignment as for OTU delimitation (see paragraph above) was used to reconstruct a phylogeny. We computed a Maximum Likelihood tree  RAxML v.We tested four different null models making different speciation assumptions with 1000 iterations each. All of these null models were included in PICANTE:Randomization of taxon labels in the distance matrix (parameter “taxa.labels”). This null model shuffles phylogenetic relationships among OTUs assuming phylogenetic evenness.Randomization of abundances within samples, maintaining species richness of elevation levels (parameter “richness”).Randomization by drawing OTUs across all samples in the distance matrix with equal probability (parameter “phylogeny.pool”). This null model assumes equal probability of AMF community membership among sites.Randomization with trial-and-swap algorithm maintaining OTU frequency in elevation levels and species richness .The four elevation levels  had distinct AMF communities  with manet al. [et al. [et al. [et al. [et al. [The effect of elevation on AMF communities corroborate the findings of Gai et al. , who stu [et al.  and Yang [et al. , who inv [et al.  found a  [et al.  observedOrdination results showed an overlap in OTU composition between 1000m and 2000m as well as between 3000m and 4000m , with liThe amount of shared OTUs in neighboring elevations would explain why studies investigating the effect of elevation in smaller gradients did not find distinct AMF communities , whereas Acaulospora became significantly more abundant at the 3000/4000 masl level in comparison to the 1000/2000 masl level (Fisher’s Exact Two-Sided Test: p = 0.0178). Abundance of all other taxa combined did not shift in higher elevations (Fisher’s Exact Two-Sided Test: p = 1), which does not mean that individual genera are equally frequent or present in all elevations. For example, there was a relatively high frequency of Claroideoglomus sequences  were especially abundant occurring in 39% (OTU17) and 34% (OTU22) of all samples  and 8.1% of all sequences  from the evergreen premontane forest in Bombuscaro, Podocarpus National Park (1000 masl), revealed 57 AMF OTUs (494 sequences). The rarefaction curve nearly reached the asymptote , and ric samples . The secces Figs . All othces Figs .Glomus  and Archaeospora (11%). The genera Claroideoglomus, Diversispora, Gigaspora, and Scutellospora had low OTU and sequence (4%) numbers . Seventy percent of the sequences belonged to the genus Glomus , with th samples . Glomus all OTUs , followeers Figs . The majers Figs .Acaulospora and 38% to the genus Glomus (Acaulospora and Glomus represented high proportions (43+40 = 83%) of the overall AMF community . This number is lower than the total number of estimated OTUs, as shown by the rarefaction curve not reaching a stable phase . Richness Glomus . With 16ommunity . All othommunity . The mos samples . As is t samples .Acaulospora and Glomus were, again, the most dominant AMF.The samples from ≈4000 masl sites at Cajas National Park (n = 123) revealed 32 OTUs (181 sequences). As is the case for the sampling at 3000 masl, the rarefaction curve showed that the area is still under-sampled . and ricAcaulospora, and Glomus sequences were most abundant (Glomus represented a high proportion (50%) of the overall AMF community  and four Glomus OTUs  with occurrences ranging from 6 to 16% of all samples  and four studies who found the same pattern in the Himalaya [Acaulospora species were the dominant colonizers of Andean potatoes growing between 2658 and 4075 masl [Acaulospora members at higher elevations [Acaulospora species was tested in the experiments by Lerat et al. [Acaulospora. Egan et al. [et al. [The dominance of ms e.g. , 44–48).–48.Glomun et al. , who obsHimalaya , 14, 15.075 masl . Other sevations , 17. Theevations  indicatet et al. , 51 and n et al.  explaine [et al.  that theAll four null models revealed the same results: Mean Nearest Taxon Distance (MNTD) suggested phylogenetic clustering for 1000 masl and 2000 masl and mean pairwise distance (MPD) indicated phylogenetic evenness for all elevation levels by failing to reject the null hypotheses . Phylogeet al. [Phylogenetic clustered AMF communities were also found in three similar elevations  in the Glacier National Park [et al.  found a Rhizophagus intraradices/irregularis/vesiculiferus-group (MaarjAM ID: VT113/114/115 - [Glomus OTUs 17 and 22) and found in our study only in this belt, have no close match neither in the MaarjAM nor the NCBI database  herdatabase . It remaAcaulospora OTUs were abundant in our study area: OTU80 (Maarjam ID: VT12), an OTU occurring from ≈1000 masl to ≈3000 masl but with main abundance in the 3000 masl level, is otherwise only known from South America (Argentina and French Guiana); OTU 82 (Maarjam ID: VT14), a generalist that also occurs in Europe and Asia; and OTU87 (Maarjam ID: VT30) a ≈3000 masl specialist in our study that has worldwide distribution and is found in many biomes.Three Like previous studies of AM fungal community structure , 58 we fThe importance of rare plant species  and theiet al. [et al. [Elevational changes correlate with many factors such as temperature, precipitation, and nutrient availability. Not only abiotic but also biotic factors change, e.g., vegetation and host plant availability. In this study, we only had few biotic and abiotic data available, and thus could not determine the driving factor behind the elevational turnover of AMF. Another factor that should be taken into account in future studies is nutrient availability, e.g., nitrogen and phosphorus sources but also carbon provided by host plants. Moser et al.  showed tet al. , 51 and  [et al.  showed tS1 Fig(TXT)Click here for additional data file.S2 FigThe horizontal bars connecting the same elevation indicate the amount of unique OTUs for this elevation. The highest number of unique OTUs both in richness and frequency was in the 1000 masl belt with a downward trend towards higher elevations. The thickness of connector lines represents the percentage of OTUs shared. The neighboring elevation levels 1000/2000 masl and 3000/4000 masl showed a high overlap of OTUs.(TIFF)Click here for additional data file.S3 Fig(TIFF)Click here for additional data file.S1 TableB1, B2, B3 Bombuscaro plot 1, 2, 3, Q2, Q5 ravines, T1, T2 ridges, Cc Cajanuma PNP Upper Montane Forest 2700 m, Cm Cajanuma PNP Upper Montane Forest 3000 m, Cl Cajanuma PNP Upper Montane Forest 2800 m, Clp Cajanuma PNP Shrub Páramo 3100 m, N Cajas NP Nero Shrub Páramo 3250 m, Tu Cajas NP Tutupali Grass Páramo 3500 m, So Cajas NP Soldados Grass Páramo 3750 m, Cpo Cajas NP Toreadora Polylepis 4000 m, Cpa Cajas NP Toreadora Grass Páramo 4000 m.Abbreviations: (PDF)Click here for additional data file.S2 TableAbbreviations same as in (PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S5 Table(PDF)Click here for additional data file.S6 Table(PDF)Click here for additional data file.S7 Table(PDF)Click here for additional data file.S8 TableA) Frequency of OTUs, divided into 4 classes: number of OTUs in <1% of the samples, in 1–5% of samples, in 5–10% of samples, in ≥10% of samples; (B) OTUs occurring in ≥ 10% of samples of the elevational belt.((PDF)Click here for additional data file.S9 TableGlomus, green: Acaulospora, blue: Diversispora, red: Gigaspora, brown: Scutellospora, rose: Claroideoglomus, cyan: Archaeospora, light green: Ambispora. The red numbers indicate the most abundant OTUs.Coloured backgrounds: Lilac: (PDF)Click here for additional data file.


Hemolytic uremic syndrome is a rare thrombotic microangiopathy usually seen in infants and children below the age of 5 years. It usually follows a bout of bloody diarrhea caused by Shiga toxin producing E coli and is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury. We report the first case of hemolytic uremic syndrome in an infant following Norovirus gastroenteritis.A nine-month-old male infant, was admitted with an 8-day history of watery, non-bloody diarrhea, vomiting and decreased oral intake. Physical exam revealed normal blood pressure, pallor and generalized edema. Laboratory findings were significant for microangiopathic hemolytic anemia, thrombocytopenia and azotemia. Stool studies with Multiplex Qualitative reverse transcriptase PCR were positive for Norovirus GI/G II. His clinical course was unusually severe, complicated by oligoanuria and worsening uremia requiring peritoneal dialysis but with eventual complete recovery.To our knowledge this is the first case of Norovirus associated HUS in an infant. Given the ubiquity of this virus as a major cause of diarrhea, together with the increased availability of Multiplex Qualitative PCR in reference laboratories, it is quite possible that we shall be seeing more such cases in the future. Hemolytic uremic syndrome (HUS) is a rare thrombotic microangiopathy (TMA) with a mean annual incidence of 6.1 cases/million children less than 5 years of age and an overall case fatality rate of 4% . PatientWe report an unusual case of HUS with severe anuric AKI in association with Norovirus  induced gastroenteritis in a nine-month-old baby which, to our knowledge, is the first infant where such a causal association is documented. We also present a brief review of other viruses reported to cause HUS and TTP.A nine-month-old male infant, was admitted with an 8-day history of watery, non-bloody diarrhea, vomiting and decreased oral intake. The baby was previously healthy and had a negative medical history.On physical examination, the patient was pale and irritable with generalized body edema, tachypnea (rate 36/min) and tachycardia (HR140/min) but no rales or murmurs were heard. No other abnormalities were noted.3), anemia  and thrombocytopenia (platelets 62× 103). Serum creatinine was 2.5, BUN, 57 uric acid, 7.6 mg/dl respectively, LDH 2293 IU/L. . Peripheral blood smear revealed evidence of microangiopathic hemolysis with schistocytes and helmet cells. Abdominal ultrasound showed echogenic but normal sized kidneys. The patient was admitted to the pediatric intensive care with the diagnosis of hemolytic uremic syndrome for possible dialysis.Initial investigations revealed leukocytosis (19 × 103) peritoneal dialysis was started after 48 h of hospitalization. The patient also received one unit of packed RBC transfusion.During his stay, the patient had persistent diarrhea, decreased oral intake, oligoanuria and generalized body edema and hypertension. There was no response to high doses of intravenous furosemide (urine output less than 0.5 ml/kg/hour). Because of progressive deterioration in kidney function , persistent oligoanuria and worsening microangiopathic hemolysis and thrombocytopenia , enterotoxigenic E coli (ETEC), enteroinvasive E coli (EIEC) and Shiga-like toxin-producing E.coli (STEC) stx1/stx2, Rotavirus A, Adenovirus, Astrovirus, but were positive for Norovirus GI/G II.Stool studies with Multiplex Qualitative reverse transcriptase PCR were negative for Additional relevant laboratory studies included massive albuminuria with an Ualb/Cr 97 mg/mg , low C3 and C4 complement of 0.56 g/L  and 0.07 g/L  respectively.After 48 h of continuous peritoneal dialysis, the patient improved clinically with progressive decrease in edema and gradual increase in urine output. Peritoneal dialysis was continued for 5 more days and his kidney function improved steadily and normalized by the 10th day when his serum creatinine was 0.3 mg/dl, and albuminuria was down to 0.13 mg/mg creatinine. Three weeks after the onset of the disease, C3 and C4 had returned to normal levels at 1.16 g/L and 0.31 g/L respectively. The patient’s hospital course and laboratory data are depicted in Figs. E. coli. The disease is characterized by microvascular thrombosis, primarily in the renal vasculature, but occasionally in multiple organs, microangiopathic hemolytic anemia and thrombocytopenia. Acute kidney injury may be mild with transient elevation of urea and creatinine and oliguria but in more than 50% it is severe and protracted, necessitating renal replacement therapy in the form of hemodialysis or peritoneal dialysis [The overall incidence of diarrhea-associated HUS is rare at around 2.1 cases per 100,000 persons/yr., with a peak incidence of 6.1 per 100,000/yr. in children younger than 5 years. While rare in occurrence, HUS is a very common cause of AKI in children, particularly in infants below the age of 4 years [dialysis  as was tWhile the vast majority of cases of diarrhea-associated HUS are secondary to STEC (O157:H7), a number of viruses have been shown recently to play an important role in the pathogenesis of thrombotic microangiopathies. Both DNA and RNA viruses have been implicated, with the cytomegalovirus (CMV) playing an important role in the development of TMA in the former, particularly in immunocompromised patients and in association with renal transplantation. Other DNA viruses  related TMAs are limited to individual case reports .Of the RNA viruses, the human immunodeficiency virus (HIV) is the most common in causing TMA. Both thrombotic thrombocytopenic purpura (TTP) and HUS have been reported in HIV patients and in patients with AIDS with a higher morbidity and mortality in the latter group . Direct Noroviruses constitute a major cause of foodborne illness and are responsible for at least 50% of all gastroenteritis outbreaks worldwide . They arTwo adults with suspected norovirus related HUS have been reported. The first was an 82-year Japanese man with hypertensive nephrosclerosis. The patient developed AKI following a bout of non-bloody diarrhea superimposed on his CKD stage 3. There was evidence of TMA and he required acute and subsequently, chronic hemodialysis. Norovirus antigen was identified in a fecal sample by enzyme immunoassay . The secIn conclusion, we have presented a case of severe HUS with anuric AKI in association with a Norovirus-related gastroenteritis. To our knowledge this is the first time such a causal relationship has been documented in an infant. With the routine immunization against rotavirus in infants, the prevalence of Norovirus gastroenteritis and its detection in stool samples by Multiplex PCR in this population is likely to rise, thus more cases of Norovirus-induced HUS may be diagnosed in the future, particularly in STEC negative patients with HUS.


The revision rate of articular surface replacement (ASR) implants continues to rise in China because of metal debris. However, there are few reports on the clinical results of ASR implants with prolonged follow-up time in China. This study investigated the clinical outcomes and the risk factors of revision surgery in patients with ASR implants.In total, 74 patients (74 hips) who underwent primary total hip arthroplasty (THA) with ASR implants over the past 4 to 10 years were retrospectively analyzed. Relevant clinical, radiographic, and biochemical data were examined.p < 0.001; 61.00 ± 3.83 vs 79.04 ± 14.49, p < 0.001; respectively). Higher acetabular abduction angle and serum Co and Cr concentration were significantly relevant to worse joint function as measured by HSS . ROC curve analysis was applied to categorize the optimal cutoff values of acetabular abduction angle and serum Cr and Co concentration for revision surgery, which were settled as 47.80°, 98.44 μg/L, and 6.95 μg/L, respectively. Overall survival of the prostheses with high acetabular abduction angle , high serum Cr concentration , and high serum Co concentration  decreased significantly than the lower groups.The average follow-up time was 88.46 (range 23–114) months, and the ASR implants of 18 hips (24.3%) were revised. Patients who received revision surgery had worse joint function with significantly lower Harris Hip Score and Western Ontario and McMaster Universities index than non-revision patients (61.11 ± 6.68 vs 85.30 ± 9.16, Evaluation of the DePuy ASR XL articulation demonstrated increased rates of revision following a longer follow-up period. High acetabular abduction angle and serum Cr and Co concentration correlated with worse clinical outcomes and high revision rate. Therefore, we advocate that patients with DePuy ASR XL implants be followed up more closely than those with other implants, especially with high acetabular abduction angle and serum Cr or Co concentration. Total hip arthroplasty (THA) is currently one of the most commonly performed and successful surgeries in China, for which can restore function, alleviate pain, and greatly improve the quality of life of patients with hip problems. However, implant failure is common due to early wear and localized osteolysis . Metal-oASR XL is a MoM bearing surface implant that is widely used in China. The reasons for revision differ from those of other prostheses. The ASR acetabular component, although stable , is subjThe revision rate of this ASR XL articulation continues to rise in China. Concerns over the early performance of this design led our institution to stop using this device after less than 4 years. The present situation is in certain center which illuminates the usage of DePuy ASR articulation; however, their follow-up time is only 2 to 5 years. Moreover, as to this series report, in China, it has not yet referred.From July 2006 to January 2010, we performed more than 100 surgeries using the ASR XL  in our institution. We took a retrospective review of our mid-term clinical experiences with 74 consecutive DePuy ASR XL THA procedures performed by three senior orthopedic surgeons. Our study aimed to assess the implant design’s performance with respect to the following: (1) the demographic characteristics of patients who underwent MoM THA, (2) the relationship between blood metal ion levels and rate of early clinical failure, (3) the cumulative survival probability at the final follow-up, and (4) the risk factors of the revision surgery.We prospectively followed 98 patients (101 hips) after second-generation MoM for primary THAs from July 2006 to January 2010. Patient data are maintained in a database that includes observations from clinical examinations, radiological data, blood Co and Cr ion levels, and cross-sectional imaging. The data were analyzed retrospectively. Prior to the initiation of this study, approval was obtained from the local ethics committee and each patient provided informed consent.In total, 25 hips were lost to follow-up; one patient was lost to high paraplegia , and one died of causes unrelated to surgery; five patients received an ASR HR in one hip and an ASR THR in the other hip and were excluded from the study; and the rest 18 patients were out of contact during the follow-up. Overall, 74 prostheses were analyzed for Kaplan–Meier survivorship using clinical and radiographic outcome measures. Seventy-four patients (74 hips) had complete metal ion data for serial outcome measurements. This subset had concomitant clinical and radiographic parameters to substantiate our metal ion data.All surgeries were performed by three senior surgeons. A posterolateral approach with detachment of the short external rotators was utilized in all procedures. The acetabulum was prepared by under-reaming by 1 mm. The ASR acetabular component is a CoCrMo alloy one-piece cup with proprietary porous coating. The outer surface of the cup consists of this porous coating with the addition of hydroxyapatite coating.The Harris Hip Score (HHS) was determined at each follow-up visit by one physician Dr. Jisheng Ran. The ROM was calculated as part of the HHS. The Western Ontario and McMaster Universities (WOMAC) index were also determined based on a questionnaire.Venous whole blood samples were obtained to determine Co and Cr levels. Blood was initially sent to the Analysis and Testing Center of Zhejiang University. The Analysis and Testing Center utilized an octopole reaction system (ORS) inductively coupled plasma mass spectrometer (ICPMS) to measure the whole blood metal ion levels. The ORS-ICPMS method has been previously described by Pei .Standardized anteroposterior (AP) and cross-table lateral radiographs of the pelvis and hip were assessed. All AP radiographs were taken with the legs in 15° internal rotation. The cup inclination angle in the frontal plane was measured against a horizontal reference line drawn along Kohler’s teardrop figures.t tests. Variables with skewed distributions  were compared using the Wilcoxon–Mann–Whitney test. Valuable correlations were calculated using Cox regression and Omnibus tests of model coefficients after adjusting for age, gender, acetabular cup, inclination, femur head size, metal ion (Co and Cr) level, body mass index (BMI), and WOMAC index; these were used to make statistical comparisons of the revision rate between groups. The ROC curve was used to estimate the performance of cup inclination, Cr concentration, and Co concentration to revision surgery. The assumption of a valuable correlation was determined analytically for each model; if the interaction between the predictor and the log of the postoperative time was significant in the standard Cox regression model, a time-varying model was used. There were no missing data for the variables included in this study. All statistical analyses were performed using SPSS software.Kaplan–Meier survivorship analysis was performed to determine the survival rates in the THA groups. Although the survival rates were not statistically compared, the differences between the revised and non-revised groups were compared. Normally distributed continuous variables  were compared by independent Of the 74 patients, there were 36 (48.6%) males and 38 51.4%) females, with a mean age of 56.12 ± 13.15 years. The primary diseases for the initial THA were 33 (44.6%) aseptic necrosis of femoral head (ANFH), 10 (13.5%) osteoarthritis (OA), 16 (21.6%) developmental dysplasia of the hip (DDH), 7 (9.5%) traumatic arthritis, and 8 (10.8%) other disease. The head size, cup size, and acetabular abduction angle of the prostheses were 45.12 ± 3.12 mm, 50.96 ± 3.90 mm, and 47.84 ± 6.35°, respectively. The average follow-up time was 88.46 months with the range of 23 to 114 months  of the ASR XL MoM THAs that required revision surgery . The acetabular abduction angle of the revision group was significantly higher than that of the non-revision group  while head size and cup size were comparable . Further, we analyzed the serum Co and Cr concentration and found both Co and Cr concentrations were significantly higher in the revision group , indicating a more severe metal abrasion  and WOMAC index   but not to WOMAC index  , high serum Cr concentration , and high serum Co concentration  decreased significantly than the lower groups  Fig. . Higher 35) Fig. . These d35) Fig. . Based oups Fig. .Fig. 2a–In the revision procedures, cystic changes were noted in nearly all cases Fig. , 8 of 18To investigate the relationships among acetabular cup inclination, head size, serum metal ion levels, and revision rate, we performed metal-on-metal THA in a consecutive series of patients. We also assessed self-reported hip function. Despite the theoretical advantages of increased head size and low-bearing surface wear, our senior surgeon handled THA with the DePuy ASR XL and had a 24.3% incidence of early revision.Although MoM articulations possess numerous theoretical advantages in implant design, concerning revision rates have been reported in many MoM implant systems. The surgeon notification provided by DePuy in conjunction with the August 2010 recall of the device noted a 13% revision rate for the ASR XL MoM THA . The revThe association between component orientation and bearing surface wear , 14, as The issue of taper debris is associated with greater tissue damage than equivalent doses from the bearing surface , that isp = 0.205, p = 0.701, respectively) and head size . However, serum Cr concentration was proved to be correlated with the acetabular abduction angle (p = 0.014) in our study, in accordance with the findings of previous studies that found higher blood metal ion levels with decreased/increased abduction angles of the acetabular component [High wear rate is the major determinant of failure of large MoM hip implants, and edge loading has been identified as the most important predictor . A largeomponent , 24. HigHigher blood metal ion values clearly correlated with a higher revision rate, ALTR prevalence, and raised blood lymphocyte levels , 26. WitAlthough we found a pseudotumor prevalence of 44.44% (8 in 18) in our study, we did not determine the potential correlation between the presence of a pseudotumor and other risk factors, including elevated metal ion levels and/or image demonstration after MoM THA. Hailer et al.  characteThere are several limitations to our study. First, this was a retrospective, randomized study. The retrospective methodology limits data collection options; indeed, 26 hips were lost to follow-up during the study. Moreover, the retrospective used in this study design lends itself to several biases, including selection and recall. A second limitation is that, during the revision procedure, we observed the formation of a pseudotumor periprosthetic but did not collect any objective images, such as ultrasonography or the more sensitive metal artifact reduction sequence magnetic resonance imaging (MARS MRI). These could have clarified the prevalence of pseudotumors preoperatively and, thus, allowed us to better assess the formation of pseudotumors. A third limitation is the relatively small sample size. Between July 2006 and January 2010, our institution performed 3,000 THAs; however, only 200 hips received the ASR XL MoM THA (100 hips complied with the follow-up visits). In China, even more than one agency had done so many THAs, our follow-up data may not delegate for the integrity. Additionally, we did not evaluate the effect of the specific stem and cup combinations due to the large variety of stems used. Differences in the wear properties and metal ion release between taper designs have been described elsewhere . LimitinThus, we advocate that patients with DePuy ASR XL implants be followed up more closely than patients with other implants, especially when symptomatic. Owing to the unusually high failure rate, poor early results with a relatively new implant design highlight the need for a national joint registry; indeed, an implant such as this one, with a poorer-than-expected survivorship, could have been more quickly identified and removed from the market. Further long-term, comparative studies of MoM and alternative bearing surfaces remain a priority for future research.Evaluation of the DePuy ASR XL articulation demonstrated increased rates of revision following a longer follow-up period. High acetabular abduction angle and serum Cr and Co concentration correlated with worse clinical outcomes and high revision rate. Therefore, we advocate that patients with DePuy ASR XL implants be followed up more closely than those with other implants, especially with high acetabular abduction angle and serum Cr or Co concentration.


In 2017, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines on the definition of hypertension, and blood pressure thresholds for initiation of antihypertensive medication. Our objective was to assess the change in prevalence of hypertension, risk factors, and identify populations recommended for treatment among Bangladeshi adults, based on the 2017 ACC/AHA guidelines. Data for this analysis were collected from a population-based nationally representative sample of 1843 Bangladeshi adults, aged ≥18 years in 2015. Hypertension was defined based on two definitions: the JNC 7 guidelines (SBP ≥ 140 or DBP ≥ 90 mmHg), and the 2017 ACC/AHA guidelines , or a self-reported diagnosis of hypertension. Based on the 2017 ACC/AHA guidelines, the prevalence of hypertension was 40.7% (95% CI: 38.5–43.0). The prevalence of JNC 7 definition of hypertension was 17.9% (95% CI: 16.2–19.7), indicating a 22.8% increase in prevalence. Based on both definitions, urban residents, older adults, adults with low physical activity, obese, abdominally obese, and diabetic adults were more likely to have hypertension. Based on current JNC 7 guidelines, only half of hypertensive adults were aware of having hypertension. Among those aware of their condition, 75% were taking medication based on self-report. Using the 2017 ACC/AHA guidelines, the prevalence of hypertension will more than double in Bangladesh. Newly diagnosed hypertensive adults will be considered high-risk for cardiovascular disease leading to a larger burden on Bangladesh’s health system. However, implementation of the ACC/AHA guidelines may improve prevention efforts where lifestyle changes are appropriate. Globally, cardiovascular diseases (CVDs) lead to one-third of all annual deaths, which is nearly 17 million total deaths worldwide , 3. The In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) published updated guidelines titled, The ACC/AHA Guidelines for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults or the 2017 Hypertension Clinical Practice Guidelines . These gAlthough the guidelines were developed with a focus on medical practice in the United States , universFor this analysis, data were obtained from a national survey to assess the burden of musculoskeletal disorders in Bangladesh. This national survey was conducted with technical support of the World Health Organization Country Office for Bangladesh and Bangabandhu Sheikh Mujib Medical University (BSMMU) . ConductZila) and subdistricts (Upazila). Within subdistricts, mauzas and mahallas are the smallest units within defined territories in rural and urban areas, respectively. Mauzas and mahallas were considered the primary sampling unit (PSU) for this sampling approach. The households within the mauzas and mahallas were the secondary sampling units. We defined a household as “a dwelling in which persons either related or unrelated were living together and using the same kitchen” [To obtain a nationally representative sample of Bangladesh, the study adopted a multistage, geographically clustered, probability-based sampling approach. Population statistics were obtained using the national census conducted by Bangladesh Bureau of Statistics (BBS) . Bangladkitchen” .The power analysis and sample size calculations were completed based on the standardized approach outlined in WHO STEPS methodology . We estiThe survey instrument collected information on the following topics: musculoskeletal disorders , and demMethods used for BP measurement have been previously described . In summOur primary outcome of interest was the prevalence of hypertension. Based on the 2017 ACC/AHA, diagnostic criteria for hypertension was systolic blood pressure (SBP) of ≥130 mmHg (millimeters of mercury) and/or, diastolic blood pressure (DBP) of ≥80 mmHg. To evaluate the change in prevalence of hypertension, we calculated the prevalence of hypertension using the JNC 7 guidelines. Based on the JNC 7, diagnostic criteria for hypertension was SBP of ≥140 mmHg and/or, DBP ≥90 mmHg. Additionally, those who self-reported to be taking anti-hypertensive medication were included in the JNC 7 definition of hypertension.We present stages of hypertension as defined by the 2017 ACC/AHA, including normal BP, elevated BP, hypertension stage 1, and hypertension stage 2 . To evalThe following variables were used as covariates for analyses: area of residence, sex, age, education, occupation, wealth index, body mass index (BMI), blood glucose levels, and waist circumference. Age was categorized into four age groups: 18–29, 30–44, 45–59 and ≥60 years. We categorized education into four groups: no education, primary education (completed grade 5 and below), secondary education (completed grade 10 and below), and above secondary education (completed grade 12 and above). Occupation was categorized into five groups for this analysis. Data on physical activity was collected based on self-report per STEPS protocol . PhysicaTo calculate BMI, we used the height (in centimeters) and weight (in kilograms) measurements. We categorized BMI to the following groups: underweight (≤18.50), normal (18.6–25), overweight (25.1–30), and obese (>30). Waist circumference was measured in centimeters (cm). Participants were categorized as abdominally obese if waist circumference was 90 cm and above for males, or 80 cm and above for females. Participants were categorized to have diabetes if their random plasma glucose level was ≥11.1 mmol/L or if they self-reported to take medication to control their diabetes.p-value of <0.10 to assess suitability for inclusion of variables in the multivariable logistic regression model. For multivariable logistic regression models, we calculated adjusted odds ratios (aOR), and 95% confidence intervals (CI) for each independent variable. We assessed collinearity to ensure there were no strong linear relationships among independent variables included in the model. All statistical procedures were performed using Stata/SE 15.0 software package.We present sociodemographic variables using median (interquartile range) for continuous variables and proportions for categorical variables. We conducted bivariate analyses by sex and age group to assess differences in hypertension prevalence. We performed chi-square tests to assess for potential differences in hypertension across select demographic variables. We performed unadjusted and adjusted logistic regression analyses to identify significant predictors of hypertension based on the two different guideline definitions. To identify potential risk factors of hypertension to be included in the model, we used bivariate logistic regression analysis and an arbitrary n = 716) and rural (n = 1127) regions of the country were included in this study. Forty-eight percent (n = 892) were male. The median age and education level of participants was 38 (29.50) years and 5 (0.9) years, respectively. The majority of the population was married (88.2%) and employed as either an industrial worker/day laborer (26.2%) or housewife (40.7%). The study population was generally evenly distributed across wealth quartiles, with the highest proportion occurring in the 2nd quartile (29.1%). Almost half of the population (44.8%) reported to use tobacco currently. The median BMI was 21.4 (19–24.5) and median waist circumference was 77.5 (70.1–86.1). Overall, the median SBP was 113 mmHg (104–124) and DBP was 77 mmHg (70–81) , based on the original JNC 7 guidelines. Using the 2017 ACC/AHA guidelines, the prevalence of hypertension among Bangladeshi adults increased to 40.7% (95% CI: 38.5–43.0). This indicated an increase in prevalence by +22.8 percentage points based on the 2017 ACC/AHA compared to JNC 7 guidelines.Figure p = 0.002) and sex (p = 0.001). Similarly, hypertension stage 1 (SBP 130–139 mmHg or DBP 80–89 mmHg) was found among 28.2% adults, and also differed significantly across area of residence (p = 0.016) and sex (p < 0.001). Hypertension stage 2 (SBP≥140 mmHg or DBP≥90 mmHg) was found among, 17.9% of adults, and differed significantly across area of residence (p < 0.001), however, there was no significant difference across gender (p = 0.095).The 2017 ACC/AHA guidelines provides defined categories of hypertension to outline levels of severity  compared to individuals aged 18–29 years. Both moderate and low physical activity increased the odds of hypertension by 1.4 (95% CI: 1.1–1.9) and 2.8 (95% CI: 1.5–5.3), respectively, when compared to the odds of vigorous physical activity. Current and past tobacco use increased the odds of hypertension by 60% and 80%, respectively, in comparison to never tobacco use. The odds of hypertension were significantly highest among those with a BMI over 30 or obesity . Additionally, the odds of hypertension among those with abdominal obesity was 2.4 times the odds of those with normal waist circumference . The odds of hypertension among diabetics were 3.4 times that of non-diabetics.The only difference in risk factors identified was current tobacco use, which was identified as a predictor of hypertension based on the JNC 7 guidelines. Additionally, for the JNC 7’s definition of hypertension, female gender and rural area of residence were no longer significant protective factors against hypertension as observed for the 2017 ACC/AHA model.We recorded treatment history of hypertension as defined by JNC 7 guidelines (current cut-off points for hypertension in Bangladesh). One hundred and ninety-nine participants (10.8%) reported to have been previously diagnosed with hypertension by a health care provider. However, 26 of these individuals did not meet the JNC 7 definition of hypertension as they did not take medication to control their hypertension and their SBP was ≤140 or their DBP was ≤90 mmHg. Therefore, 52.4% of hypertensive adults, per the JNC 7’s definition, were previously diagnosed with the condition. The proportion of men and women who self-reported to be previously diagnosed with hypertension by a health care provider was higher among urban residents  than among rural residents  Fig. . Howevern = 199), 75.4% reported to take medication to control their hypertension. Among urban participants, women more frequently (80.9%) self-reported to take hypertension medication than men (74.5%)  Fig. . Among r5%) Fig. .n = 150) of hypertensive participants reported to take medication to control their hypertension, 61% continued to have high BP levels indicating uncontrolled hypertension at study measurement. Among the 61% with uncontrolled high BP, the average systolic BP was 148.3 mmHg (SD:16.4) and average diastolic BP was 94.1 mmHg (SD: 9.7). Additionally, their average age was 49.9 years; the average age among men was 48.4 years and among females was 50.8 years.Although about three-quarters . This prevalence increased to 40.7% when the 2017 ACC/AHA criteria for diagnosis of hypertension was applied, indicating a 22.8% increase in prevalence. Predictors of increased odds of hypertension did not change across the two definitions of hypertension, however, being female and residing in a rural area were significant protective factors against hypertension per the 2017 ACC/AHA hypertension definition only. Overall, the Bangladeshi hypertensive adult population is under-treated, particularly the rural population. Using the existing guidelines, half of hypertensive adults were aware of their condition, and one-quarter were not taking medication to control their hypertension. With the new guidelines, a higher proportion of adults with high BP will be recommended for pharmacologic treatment to avoid subsequent cardiovascular disease outcomes .The prevalence of hypertension among Bangladeshi adults on a national level has been previously studied , 24, 25.Predictors of hypertension among Bangladeshi adults have been previously evaluated, however, here we present a comparison using the 2017 ACC/AHA and the current JNC 7 guidelines diagnostic criteria used in Bangladesh. For both definitions of hypertension, we find that increasing age, low physical activity, increasing BMI, abdominal obesity, and diabetes are predictors of having hypertension. Prior national surveys have identified these predictors among Bangladeshi adults , 29 and Published in 2013, the National Guidelines for Management of Hypertension in Bangladesh were developed to provide country-specific guidelines for effective management of hypertension by primary care providers in a low-resource context . The curThe 2017 ACC/AHA guidelines strongly support nonpharmacologic interventions as primary and secondary approaches to lowering BP. Such interventions include, following a heart-healthy diet, such as the dietary approach to stop hypertension (DASH) diet, reduction in dietary sodium intake (<1500 mg/d or at least 1000 mg/d reduction), potassium supplementation (3500–5000 mg/d), physical activity increase (90–150 min per week), moderation of alcohol intake (≤2 drinks per day in men and ≤1 drink per day in women), and weight loss. Most of these interventions have been shown to reduce BP in randomized control trials by 5–10 mmHg , 32–34. Adherence to treatment should also be considered as a major factor in the decision to prescribe either lifestyle or pharmacological treatment to patients. In our study, we found that although 75% of hypertensive participants with known diagnosis reported to take medication, 61% of these hypertensive adults continued to have high BP. This may be due to poor adherence to treatment, which has been previously documented as a concern among adults both in urban and rural areas of Bangladesh –15. AddiOur study has several strengths to be highlighted. Data collected was of a nationally representative sample, and included Bangladeshi adults aged 18 years or above. We present novel prevalence data of hypertension among adults aged 18 years and above, as prior studies have started their cohorts at older ages , 24, 25.In addition, our study has several limitations which should be considered. As our study design is cross-sectional we are unable to assess causality between the observed associations and hypertension. Questions regarding prior diagnosis of hypertension and treatment of hypertension are vulnerable to recall bias; however, when available, doctor’s prescription or medicine labels were checked. Physical activity may be misclassified due to recall bias; we assume there may be underreporting of low physical activity . AdditioIf adopted, the 2017 ACC/AHA guidelines may lead to an increase in burden of hypertension among Bangladeshi adults aged 18 years and above from about 18% to about 40%. In response to the potential doubling of the burden of hypertension, the Government of Bangladesh will need to take several steps to implement appropriate programs for prevention and treatment of this chronic disease. Preventive methods such as lifestyle changes and medication should be recommended by primary care providers in Bangladesh to avoid the future development of CVDs. National initiatives such as training community health workers to deliver primary care and implementing universal health coverage should be considered to curb the spread of hypertension and consequent CVDs in Bangladesh.Few national-based studies have been conducted in Bangladesh to assess the prevalence of hypertension in Bangladesh, and currently there is no relevant data available on adults aged 18–25 years.Risk factors for hypertension among Bangladeshi populations include high body mass index, age, area of residence, and gender.The majority of cases of hypertension in Bangladesh are untreated and undetected.Here, we provide the first analysis of prevalence of hypertension using the American College of Cardiology and American Heart Association’s (ACC/AHA) 2017 Hypertension Clinical Practice Guidelines, in comparison to the existing guidelines, called Joint National Commission 7, guidelines among Bangladeshi adults aged 18 years and above.This study shows that with the adoption of the 2017 ACC/AHA guidelines, the prevalence of hypertension will be more than double in Bangladesh.National efforts to improve treatment options among hypertensive adults should be prioritized, as the Non-Communicable Disease (NCD) Control Program of the Government of Bangladesh prepares to respond to the potential increase in prevalence of hypertension and subsequent burden on the health care system.


Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related mortality worldwide. Sorafenib is the standard first-line treatment for advanced HCC, but its efficacy is limited. Apatinib is a small-molecule tyrosine kinase inhibitor that has shown promising antitumor effects in gastric and non-small cell lung cancers in clinical trials, but there have been only a few studies reporting its anti-HCC effects in vitro and in HCC xenograft models. Hence, our present study systemically investigated and compared the antitumorigenic and antiangiogenic efficacy of apatinib and sorafenib in HCC in vitro and in vivo using multimodality molecular imaging, including bioluminescence imaging (BLI), bioluminescence tomography (BLT), fluorescence molecular imaging (FMI), and computed tomography angiography (CTA). Moreover, the safety and side effects of the two drugs were systemically evaluated. We found that apatinib showed a comparable therapeutic efficacy to sorafenib for the inhibition of HCC. The drug safety evaluation revealed that both of these drugs caused hypertension and mild liver and kidney damage. Sorafenib caused diarrhea, rash, and weight loss in mice, but these effects were not observed in mice treated with apatinib. In conclusion, apatinib has similar antitumorigenic and antiangiogenic efficacy as sorafenib in HCC with less toxicity. These findings may provide preclinical evidence supporting the potential application of apatinib for the treatment of HCC patients. Researchers have combined different sophisticated imaging techniques to assess the safety and efficacy of liver cancer therapy in animal models. Many hepatocellular carcinoma (HCC) patients respond to sorafenib, but this drug is expensive and may cause severe side-effects. Qian Liang at China’s Institute of Automation, Beijing, and colleagues have employed cutting-edge imaging technologies to study an alternative drug, apatinib, which has shown promise for stomach and lung cancer and has an excellent safety profile. Using bioluminescence imaging, the researchers could directly visualize apatanib-mediated inhibition of tumor growth in live mice much earlier than would be possible with other methods. The researchers subsequently used additional imaging techniques to demonstrate that apatanib inhibits tumor blood vessel growth. These findings reveal a promising alternative treatment for HCC, as well as a powerful strategy for drug testing in animals. The disease is often detected at a late stage. Computed tomography (CT) and magnetic resonance imaging (MRI) are used to evaluate the efficacy of clinical drug treatment according to the gold standard response evaluation criteria in solid tumors2. This approach is only suitable for monitoring changes in tumor anatomy in advanced hepatocellular carcinoma (HCC) patients. However, delayed assessment can result in patients missing the optimal treatment window, which reduces the 5-year survival rate. As such, more sensitive and effective imaging methods for the early evaluation of drug efficacy are needed in both preclinical and clinical studies.Liver cancer is a highly fatal cancer worldwide and is the second leading cause of cancer death in men and the sixth in women4. Optical molecular imaging techniques, such as bioluminescence imaging (BLI) and fluorescence molecular imaging (FMI), are essential in cancer detection, drug development, and evaluation of treatment response for their high sensitivity, no radioactivity, ease of use, and relatively low cost5. However, these methods suffer from the limited penetration depth and the lack of anatomical structure details. Combining optical imaging with CT or MRI could potentially overcome these problems.Molecular imaging allows noninvasive and dynamic assessment of physiological processes at the molecular and cellular levels in intact living subjects, which can reveal biological activity and drug responses, thereby allowing the assessment of drug efficacy at an early therapeutic stage6. However, in some patients, it is necessary to reduce the drug dose to avoid side effects such as diarrhea, vomiting, and hand-foot syndrome8, which limit the antitumor efficacy. Moreover, the high cost of sorafenib makes it untenable for long-term treatment of HCC patients. For this reason, new targeted drugs for HCC are currently being developed and tested. Since HCC is characterized as a highly vascularized tumor, suppressing angiogenesis is an attractive treatment strategy10. Sorafenib can effectively block tumor angiogenesis in an HCC model and targets multiple receptor tyrosine kinases (RTKs), including vascular endothelial growth factor receptor (VEGFR)-2, platelet-derived growth factor receptor (PDGFR), FLT3, Ret, and c-Kit11. Similarly, apatinib is a small-molecule tyrosine kinase inhibitor that can inhibit HCC progression through multiple RTKs, including VEGFR-2, PDGFR, IGF-IR, and Dtk12. In addition, apatinib has shown promising antitumor effects in gastric and non-small cell lung cancers in clinical trials10. Surprisingly, only a few studies reported its anti-HCC effects in vitro and in mouse xenograft models of human HCC13.Targeted drug therapy is the most common treatment for advanced cases of HCC, and sorafenib is considered the standard first-line treatment for advanced HCCIn this study, we systemically investigated and compared the antitumor effects of apatinib and sorafenib on HCC using multimodality molecular imaging approaches. Drug treatment efficacy was assessed in vitro using several human HCC cell lines and in vivo using subcutaneous and orthotopic HCC mouse models. The safety and side effects of these drugs were also systemically evaluated. Our study provides preclinical evidence for the efficacy of apatinib in the treatment of HCC patients.d-luciferin were obtained from PerkinElmer. Fenestra VC was from ART Advanced Research Technologies .HepG2 and Hep3B HCC cell lines were obtained from the American Type Culture Collection . HUH7, SMMC-7721, and BEL-7402 HCC cell lines were obtained from Shanghai Genechem Co. . The HepG2-Red-fLuc cell line was purchased from PerkinElmer . Dulbecco’s modified Eagle’s medium (DMEM), Roswell Park Memorial Institute (RPMI) 1640 medium, and fetal bovine serum (FBS) were obtained from HyClone . Apatinib and sorafenib were obtained from Jiangsu Hengrui Medicine Co.  and Bayer , respectively. AngioSense 750 EX and 2).HepG2-Red-fLuc, HUH7-fLuc, and Hep3B cells were cultured in DMEM and SMMC-7721-fLuc, and BEL-7402 cells were cultured in RPMI 1640 medium supplemented with 10% FBS in a controlled environment  and sorafenib  were added. After 24 h, Cell Counting Kit (CCK)-8 solution was added to each well, followed by incubation for 4 h, and the absorbance at 450 nm was measured with a microplate reader . The cell survival rate was calculated using the following formula:For HCC cells expressing the luciferase gene  grown in 96-well plates, BLI was performed after 24 h of drug application to evaluate the treatment efficacy.Male athymic Balb/c nude mice (4–5 weeks old) were purchased from Vital River Laboratory Animal Technology Corp. . Animal experiments were performed according to the guidelines of the Institutional Animal Care and Use Committee of Peking University (permit no. 2011-0039).6 HepG2-Red-fLuc or SMMC-7721-fLuc cells into the right lower flank of mice. The orthotopic liver tumor model was generated by inoculating 1 × 106 HepG2-Red-fLuc cells into the liver lobe of mice through laparotomy under isoflurane anesthesia. After the surgery, the peritoneum and skin of the mice were sutured with absorbable surgical lines, and the mice were placed in a warm box until they woke up.The subcutaneous liver tumor model was established in Balb/c nude mice by injecting 1 × 1014. The mice treated with apatinib were orally gavaged with 70 mg/kg apatinib every 2 days for a total of six times, while the sorafenib group was gavaged with 62 mg/kg sorafenib every 2 days. The control mice were given an equal volume of diluted solvent with sterile water.After inoculation of liver tumor cells, liver tumor growth was monitored by measuring BLI signal intensity and tumor volume. At 7 days after liver tumor cell implantation, subcutaneous or orthotopic tumor-bearing mice were randomly divided into the control, sorafenib and apatinib treatment groups. Apatinib and sorafenib were dissolved in 1:1:8 DMSO/Cremphor EL/PBSd-luciferin (150 mg/kg body weight) for 8 min. BLI was carried out with an IVIS spectrum optical imaging system (PerkinElmer) every 2 days during drug treatment for a total of six times. Changes in the BLI signal intensity in regions of interest at different time points were quantitatively analyzed to evaluate the antitumor efficacy of the drugs.Before imaging, mice were anesthetized with 2% isoflurane and intraperitoneally injected with 15. The BLI system for capturing bioluminescent signals on the body surface consisted of an electron-multiplying charge-coupled device camera (EMCCD)  and imaging stage16.A schematic illustration of the μCT/BLI system is shown in Fig. d-luciferin for 8 min; it was then fixed on the imaging platform with a respiratory mask connected to the gas anesthesia vaporizer17. Images were captured with the EMCCD camera at different angles  with the following parameters: binning = 1 and exposure time = 10 s. The 3D anatomical data were obtained by μCT scanning. The major organs, including muscles, heart, lung, liver, kidney, and bone, were segmented to generate the heterogeneous mouse model. Moreover, the assembled mouse body was discretized into the surface and volumetric mesh data for BLT reconstruction. 3D BLT reconstruction procedure of the orthotopic liver tumor model is shown in Fig. On day 20 post-drug treatment, the three-dimensional (3D) tomographic imaging data and the bioluminescent surface signals were acquired using the μCT/BLI system, and the 3D distribution of bioluminescence of the orthotopic liver tumor in the three groups was reconstructed. Before BLT imaging, the mouse was anesthetized with 2% isoflurane and intraperitoneally injected with ex vivo optical imaging .To investigate whether apatinib and sorafenib could inhibit tumor angiogenesis in the orthotopic liver tumor model, we carried out FMI of tumor angiography on day 20 post-drug treatment. AngioSense 750 EX, a fluorescent blood pool imaging agent, was injected through the tail vein at a dose of 2 nmol/100 μL per mouse. FMI images of orthotopic tumors were acquired at different time points . We also acquired BLI images of the tumors at 48 h. Mice were sacrificed, and liver lobes with tumors were dissected for 18. CTA data were processed with Amira v.5.2.1 .Moreover, on day 20 post-drug treatment, the Fenestra VC contrast agent (10 μL/g) was intravenously injected into the orthotopic HCC tumor-bearing mice approximately 15 min prior to imaging by CT angiography (CTA)Body weight was measured using an electronic balance every 2 days during treatment. Liver tumor size was measured using digital Vernier calipers, and the tumor volume was calculated using the following formula:Mouse urine samples were collected via metabolic cages  after drug treatment for analysis of 24 h urine creatinine and urine protein levels. Liver function was evaluated by monitoring serum alanine transaminase (ALT) and aspartate transaminase (AST) levels after treatment in three groups. The blood pressure of tumor-bearing mice before and after treatment was measured noninvasively with a blood pressure monitor .At the end of drug treatment, the mice were sacrificed, and the major organs, including the heart, liver, spleen, lung, and kidney, as well as tumors, were removed. The tissue specimens were fixed in 4% formalin and embedded in paraffin, and 5-μm sections were cut and stained with hematoxylin and eosin (H&E). Images were acquired with a light microscope .2O2 for 10 min, and antigen retrieval was performed for 10 min at room temperature. The sections were blocked by incubation in 10% goat serum for 1 h and then incubated overnight at 4 °C with primary antibody against CD31  or Ki67 . The following day, the sections were incubated with secondary antibody at 37 °C for 20 min, and immunoreactivity was visualized with a diaminobenzidine color reagent kit . Apoptotic cells were detected with a TUNEL apoptosis detection kit .We carried out CD31 and Ki67 immunohistochemistry and TUNEL staining of the tumor samples on day 25 post-treatment. Tumor samples were fixed in 4% formalin and embedded in paraffin. The tissue blocks were cut into sections at a thickness of 5 μm that were deparaffinized and rehydrated. Endogenous peroxidase activity was quenched by incubation in 1% Ht-test, with a P-value < 0.05 considered statistically significant. Concretely, * indicates P-value < 0.05, ** indicates P-value < 0.01, and *** indicates P-value < 0.001.Data are expressed as the mean ± standard error of the mean and were analyzed using Prism 5 software . Differences in mean values of different groups were compared with Student’s The cytotoxicity of apatinib and sorafenib to HUH7, HepG2, Hep3B, SMMC-7721, and BEL-7402 human hepatocellular cell lines was evaluated with the CCK-8 assay. The cells were treated with different concentrations of drugs for 24 h. Both apatinib and sorafenib inhibited the proliferation of HCC cells in a dose-dependent manner Fig. . AccordiExpression of the luciferase gene in the HepG2-Red-fLuc, SMMC-7721-fLuc, and HUH7-fLuc cell lines after drug treatment was detected by BLI Fig. . BLI sigP < 0.05); on day 18, the signal intensities of mice in the apatinib and sorafenib groups were (0.4478 ± 0.05589) × 108 and (0.5603 ± 0.1960) × 108 photons/s/cm2/sr, respectively, compared to (1.553 ± 0.1501) × 108 photons/s/cm2/sr in control mice. In mice bearing SMMC-7721-fLuc cell-derived tumors, the BLI signal intensities of apatinib-treated and sorafenib-treated mice were (1.939 ± 0.5231) × 109 and (1.429 ± 0.5185) × 109 photons/s/cm2/sr, respectively, compared to (4.168 ± 0.4377) × 109 photons/s/cm2/sr in the control group on day 18. These results indicate that both apatinib and sorafenib can effectively inhibit HCC growth.We monitored the progression of subcutaneous (HepG2-Red-fLuc and SMMC-7721-fLuc) and orthotopic (HepG2-Red-fLuc) liver tumors in mice treated with apatinib or sorafenib by BLI using BLI signal intensity as a measurement of the antitumor efficacy of the drugs Fig. . The BLIWe also measured tumor volumes using digital calipers and found that tumors in the control group were more massive than those in the apatinib and sorafenib treatment groups, with no statistically significant difference between these two groups Fig. . Importa20. We established this model to simulate the natural tumor microenvironment and monitored orthotopic liver tumor growth during drug treatment by BLI  and sorafenib (1.727 ± 0.05054 μmol) relative to control animals (0.8883 ± 0.09812 μmol) Fig. , whereas23. We found that the levels of both enzymes were higher in the apatinib and sorafenib treatment groups than in control mice  mice and those treated with apatinib (60.91 ± 2.397 mmHg) and sorafenib (60.64 ± 1.642 mmHg) prior to drug administration Fig. . We thenIn addition to the abovementioned drug-induced side effects, rashes and diarrhea were observed in mice treated with sorafenib but not in those treated with apatinib Fig. . The medIn this study, we assessed the therapeutic efficacy of apatinib and sorafenib in HCC by multimodality molecular imaging. BLI, BLT, FMI, and CTA were fully utilized to sensitively and dynamically assess the antitumorigenic and antiangiogenic effects of drug treatment and to examine the side effects. Our results demonstrated that apatinib inhibited HCC growth and angiogenesis both in vitro and in vivo with efficacy that was comparable to that of sorafenib but with fewer side effects. In general, our preclinical assessment of apatinib demonstrates that it has clinical application potential for the treatment of HCC in patients.We used multimodal molecular imaging to evaluate the therapeutic response, with appropriate adjustments made in the experimental protocol. This approach is critical in the evaluation of antitumor drugs. BLI is a more sensitive and effective method for detecting cancer lesions and evaluating drug treatment efficacy than tumor volume measurement since it provides quantitative information on living tumor cells before and after treatment. In this study, the inhibition of HCC cell proliferation by apatinib was detected in HepG2-Red-fLuc subcutaneous tumor-bearing mice at 12 days post-treatment by BLI, whereas the difference relative to the control mice was only observed on day 18 by measuring tumor volume. Moreover, the latter is not feasible for orthotopic HCC models at early stages, whereas the inhibitory effects on tumor growth utilizing BLI are detectable as early as 6 days post-treatment. While BLI can only provide 2D information on orthotopic HCC tumors, BLT can reveal details of both tumor growth and structure. In the present study, the 3D bioluminescence distribution of orthotopic liver tumors was reconstructed to evaluate drug treatment efficacy, which provided both the tumor location and volume information at the molecular and cellular levels.9 and is known to be inhibited by both apatinib and sorafenib11. We carried out FMI using the AngioSense 750 EX fluorescence imaging contrast agent; however, although this probe can provide sensitive and specific imaging information, the fluorescence signal cannot be detected in deep tissues. Since the CT signal is independent of imaging depth, we performed 3D CTA of orthotopic liver tumors using the Fenestra VC imaging contrast agent. The in vivo FMI and CTA imaging results revealed that apatinib and sorafenib suppressed angiogenesis relative to vehicle-treated control animals. Immunohistochemical analysis of CD31 and Ki67 and TUNEL positivity confirmed that tumor angiogenesis and tumor cell proliferation were inhibited, whereas apoptosis was enhanced by drug treatment.Angiogenesis plays a vital role in liver tumor growthThe side effects of antitumor drugs are a critical clinical consideration. In this study, we monitored changes in urine creatinine and protein levels, serum ALT and AST levels, and blood pressure to assess the toxicity of apatinib and sorafenib. The results showed that both drugs caused some degree of liver and kidney dysfunction and increased blood pressure, although apatinib did not cause other side effects, such as diarrhea, rashes, and weight loss, that were associated with sorafenib treatment. Thus, apatinib may be a relatively safer alternative for HCC treatment than sorafenib.In conclusion, our results demonstrated that multimodality molecular imaging is a more sensitive and functional method for evaluating the therapeutic effects of apatinib on HCC, as it revealed early aspects of the drug treatment response. Apatinib has antitumorigenic and antiangiogenic effects in HCC both in vitro and in vivo that are comparable to those of sorafenib but has fewer toxic side effects. Our findings provide preclinical evidence for further investigations on the clinical applicability of apatinib to HCC patients.Supplementary Information


While normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable.To investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for ‘significant apical descent using receiver–operator characteristics (ROC) statistics.Retrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure “C”.The records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 . POP-Q point “C” was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 .A cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy. The prevalence of pelvic organ prolapse (POP) is increasing due to increasing life-expectancy and changing demographics , 2, and The ICS POP Quantification (POP-Q) system defines the position of the most distal portion of the prolapse in each compartment in relation to the level of the hymen, and classifies prolapse into stages 0–4. In parous women anterior and/or posterior compartment prolapse stage 1 is common and mostly asymptomatic and suggested cutoffs for predicting prolapse symptoms range between 0.5 cm proximal and 0.5 cm distal to the hymen , 10, 14.This study was undertaken to investigate the relationship between prolapse symptoms and apical ICS POP-Q measurement in women with and without previous hysterectomy.The aim was to establish optimal cut- off levels for predicting symptoms and bother of prolapse and hereby define ‘normality’ using receiver–operating characteristics (ROC) curves.This was a retrospective analysis of patients seen for assessment of lower urinary tract or pelvic floor disorders between March 2011 and December 2017 in a tertiary urogynaecological unit. Evaluation included a standardized interview, a clinical assessment using the ICS Pelvic Organ Prolapse Quantification (POP-Q) system  and 4 D For statistical analysis, the POP-Q measure “C“, which relates to the position of the cervix or vault relative to the hymen, was regarded as the explanatory variable, with symptoms of prolapse (Y/N) being the main outcome variable. Logistic regression was used to test for univariate associations between prolapse symptoms and patient risk factors: age, BMI, parity, previous forceps delivery, avulsion and previous hysterectomy and previous prolapse/incontinence surgery. Receiver–operator characteristics (ROC) curves were prepared for symptoms of prolapse and C in women with and without previous hysterectomy, controlling for risk factors identified on univariate analysis. The areas under the ROC curve (AUC) were calculated as a measure of predictive performance, and cutoffs were determined. To control for multi-compartment prolapse, ROC statistics were repeated after excluding women with dominant prolapse in other compartments (defined as POP-Q ≥ 2 stage higher than uterine/ vault prolapse), leaving 2050 women for analyses. The relationship between VAS prolapse bother score and POP-Q measures was also assessed using univariate and multivariate linear regression analysis.Statistical analysis was carried out using the software SAS V 9.3  and SPSS V 20  and p<0.05 was considered statistically significant. Logistic regression analysis and ROC statistics were performed. The study was part of a retrospective study approved by the local human research ethics committee . No consent was obtained, because the study was undertaken retrospectively and analyzed anonymously.The records of 3010 women presenting during the study period were available for analysis. Women were predominantly of Caucasian origin, and from diverse socioeconomic backgrounds. Mean age was 56.9  years, with 64.4% (n = 1937) being postmenopausal, and the mean body mass index (BMI) was 29.1 . Median parity was 2 (range 0–9) with 89.5% vaginally parous and 26.3% (n = 792) reporting at least one forceps delivery. Previous hysterectomy was reported by 947 women (31.5%), and 690 (22.9%) had had previous prolapse and/or incontinence surgery.Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 . On clinical examination the following POP-Q measures were recorded: “C”: mean -4.3 ; “Ba”: mean -0.7 , “Bp”: mean -1.1 . Levator muscle avulsion was diagnosed in 716 (23.8%), being unilateral in 457 (15.2%) and bilateral in 259 (8.6%).On univariate analysis, apical descent, i.e. POP-Q point “C”, was highly significantly associated with symptoms of prolapse (p <0.0001) and ROC statistics resulted in an AUC of 0.711 (95% CI 0.693–0.729). ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). We determined cut- offs for ‘significant prolapse’ of C = -5 for women with uterus in situ  and after hysterectomy , with a cut-off of -5.5 performing marginally better  after hysterectomy, see Controlling for multi-compartment prolapse (n = 2050) further improved the models for “C” and prolapse symptoms, resulting in an ROC AUC of 0.782 and 0.720 for women with uterine and vault prolapse, respectively. For prediction of prolapse symptoms in this subgroup, cutoffs were set at C = -5  and after hysterectomy , see Linear regression analysis of VAS scores for prolapse bother showed highly significant relationships with POP-Q measures “C”, “Ba” and “Bp”, but also risk factors age, BMI, parity, avulsion, previous forceps delivery and previous hysterectomy see . All POPAn evidence-based definition of clinically significant apical prolapse is important for both clinical care and research, and needs to be valid for women with and without uterus , 11. In It is recognized that this cutoff is distinct higher than previously suggested cutoffs for prediction of POP symptoms using ROC statistics , 10, 18.Translabial ultrasound is another easily accessible, safe and inexpensive technique for specifying the degree of prolapse in each compartment, and cutoffs for clinically relevant prolapse have been established using ROC statistics , 20. ForIn a recent systematic review the definitions of clinically significant apical prolapse for study inclusion and surgical success and failure were analyzed. In 35 randomized controlled trials the definitions were found to be either absent or highly variable, ranging from apical prolapse >-1cm to >+ 1 cm to > 50% of total vaginal length. The presence of prolapse symptoms as an inclusion or surgical success criteria was used in 46% and 29% of studies, only .Our results highlight the need to consider compartments separately from each other and define specific cutoffs for apical and anterior/posterior descent. As far as the authors are aware, this is the first study to do so. ROC statistics for uterine descent and prolapse symptoms have been described using translabial ultrasound . HoweverThe study is also limited by the retrospective design and the tertiary urogynaecologic unit setting. The patients were predominantly of Caucasian origin, and results may only pertain to similar populations. Interviews and clinical examination were not consistently blinded against each other, and this may have introduced measurement bias.A considerable strength of the study is the large consecutive dataset of 3010 patients. This sample size allowed us to examine women with and without uterus separately, and excluding women with dominant prolapse in other compartments.In conclusion, the previously proposed cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy. Prospective studies with standardized detailed questionnaires should help to confirm these findings.