Introduction: The cardiopulmonary bypass may have multiple systemic effects on the body organs as liver. This prospective study was planned to explore further the incidence and significance of this change.Methods: Two hundred patients with coronary artery bypass grafting (CABG), were randomly selected for the study. Total and indirect bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase were measured preoperatively and at 24, 48 and 72 hours, following coronary artery bypass grafting. Postoperative value of the liver function tests with respect to hypothermia or hypotension were compared by one way analysis of variance for repeated measure and compared with t test. Patient’s characteristics with bilirubin value (≤1.5 mg or >1.5 mg) were compared with t test.Results: A significant increase of total bilirubin, aspartate aminotransferase, and alkaline phosphatase were noted in the third postoperative day. Significant relation was seen between hypotension and alkaline phosphatase, and aspartate aminotransferase change but hypothermia had not affected alanine aminotransferase, total bilirubin and indirect bilirubin change. Pump time, alanine aminotransferase in third postoperative day and direct bilirubin in first and second day of postoperative period had significant relation with pre and post-operative bilirubin change.Conclusion: Transient but not permanent alterations of hepatic enzymes after coronary artery bypass grafting presumably attributed to the decreased hepatic flow, hypoxia, or pump-induced inflammation. CPB is non physiologic circulation and the patients are subjected to a various degree of body organ dysfunction.2 The careful recent medical literature review revealed that most studies have been focused on methods to protect organs from adverse effect of CPB; however, most of these studies missed evaluation of the liver function and focused on organs such as heart, lung and kidney. Paparella et al3 showed that in the high-risk cardiac surgery, about 10% of patients who received CPB, experience hepatic injury, which directly affects morbidity and mortality of patients. Wark supposed two main pathophysiologic mechanisms for the post CPB hepatic injury that includes the systemic inflammatory response syndrome and oxidative stress.4 However, Edmunds exhibits that most of these pathophysiologic mechanisms are based on centrilolular sinusoid ischemia and subsequent reperfusion injuries. Others mechanism that propounded by Hayashida et al5 include drug induced hepatic injury or systemic inflammatory reaction by CPB. High mortality of post CPB liver injury needs to convenience mechanisms of hepatic injury induced by CPB. Some trials have shown that the consumption of coagulation factors during CPB leads to reduced coagulation factors and compromised liver function by micro thrombi formation in centrilolular hepatic sinusoids.6 On the other hand, in some controversial studies, short CPB time less than two hours were not associated with compromised hepatic function test.7 Furthermore, an elevation of serum liver enzymes after uncomplicated CPB has been reported in some studies. These changes could to be attributed to splanchnic ischemia caused by centrilobular hepatic cell ischemia and shocked liver.8 This study was planned to explore, the incidence and clinical significance of serum liver test changes after CPB.The institution of cardiopulmonary bypass (CPB) in open cardiac surgery is associated with some body organ dysfunction.9, PT or PTT >1.5 × of reference laboratory value or fibrinogen level less than 1 g/l. Cell saver machine and auto transfusion system were not applied in ICU. Packed red blood cells were used during CPB time as the patient’s hemoglobin reduced to 7.0 g/dl. Postoperative indication for packed red blood cells includes: (1) hemoglobin <8.0 g/dl, (2)excessive mediastinal bleeding more than 600 ml in three consecutive hours. Others blood products, such as platelets and fresh frozen plasma and cryoprecipitate were transfused as patient’s condition warranted. Five liver function parameters were measured preoperatively and at 24, 48 and 72 hours following surgery: Total and indirect bilirubin (TB-IB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP). Results were expressed as mean value ± standard deviation. Biochemical analysis  was performed using an automated analyser . We decided to distinguish patients with bilirubin of ≤1.5 mg from those with bilirubin of more than 1.5 mg with respect to preoperative, intraoperative and postoperative variables. Strict exclusion criteria were adopted in order to eliminate any known cause of possible liver function disturbances. The postoperative value of liver function test (LFT) in three consecutive postoperative days with respect to hypothermia or hypotension was compared by one way analysis of variance (ANOVA) for repeated measures and the preoperative value of liver function test compared with postoperative (three consecutive days) with t test. Patients’ characteristics were compared using t test for continuous variables . In the subgroups of the patients with or without hyperbilirubinemia, t test and chi-square test were used for continuous and categorical variables on each post operative day, consequently. Statistical analysis was performed with the statistical package for the social sciences (SPSS 11.5). P-values less than 0.05 were considered statistically significant.A prospective study was carried out at our center, 400 patients scheduled to undergo first time coronary artery bypass grafting (CABG) who had full criteria in entering to study, were randomized, with a computer generated random number, patients were consecutively allocated to singular or plural nouns. One hundred patients with singular number and 100 patients with plural number entered to study. The exclusion criteria were set up in order to eliminate any other known cause of possible liver function disturbances that includes right heart failure, combination of valve and coronary artery disease (CAD), Gilbert syndrome, acute inflammation of gallbladder or any other complication of gallstone disease, active viral and non viral hepatitis and, hematological disorders, toxic anesthesia drugs and incomplete data. The operative technique was similar in all patients. General anesthesia was induced and maintained with total intravenous anesthesia, consisting of 2% propofol (100 µg/kg/min) and remifentanil (0.15 µg/kg/min). And atracurium (5 µg/kg/min) was infused intravenously. After anesthesia, a median sternotomy was performed, followed by routine aortic and atrial cannulation. CPB was established using membrane oxygenation, non-pulsatile perfusion, and moderate systemic hypothermia. Myocardial protection was achieved by cold hyperkalemic crystalloid cardioplegia and topical cooling with iced slush and cold saline solution. Cardioplegia was administered in a retrograde and antegrade fashion in all patients. CABG was performed using the left internal mammary artery and reversed saphenous vein in most instances. Transfusion of packed red blood cell concentrates was accomplished when the hematocrit or hemoglobin (Hct/Hb) value was less than 0.20/7 g/dl. In the open heart surgery intensive care unit (ICU), blood transfusion was performed when a Hct/Hb level reach to 0.25/8 g/dl or less. Postoperative transfusion of fresh frozen plasma, platelets or cryoprecipitate was fulfilled in the presence of active bleeding (more than 200 ml/h in 3 consecutive hours) and presence of coagulation disturbances (platelet count less than 80 × 10P = 0.001). The preoperative ALT (47 ± 14 U/ml) was increased up to 4% in third postoperative day . The preoperative alkaline phosphatase (120 ± 61 U/l) was increased up to 34% in third postoperative day  and 80 men 40%), with a mean age of 58 ± 5 years. The mean duration of the CPB time was 66 ± 8 minutes. The mean duration of the aortic cross clamp time was 44±5 minutes. The preoperative TB (1 ± 0.4 mg/ml) was increased up to 20% in third postoperative day (1.2 ± 0.4 mg/ml) but there was not significant differences between preoperative value and first and second postoperative day. Likewise, the preoperative IB (0.35 ± 0.2 mg/ml) was decreased up to 45% in third postoperative day (0.22 ± 0.2 mg/ml). This difference was not statistically significant between preoperative value and first and second day. The changes in the level of liver amino transferase enzymes were more remarkable. The preoperative AST (18 ± 11 U/ml) was increased up to 7.3% in third postoperative day , has significant influence on ALT in the third postoperative day, however, normothermia has significant effect on AST on second post operative day. Results of our study showed that most sensitive test for postoperative evaluation of hepatic function in hypothermic and normothermic CPB is AST and ALT consequently. In Wang study,predictors of possible risk factors for postoperativehyperbilirubinemia were the numbers of replaced valves,preoperative right atrial pressure, and preoperative TBconcentration.12 We believe that high right atrial pressure in Wang study caused hepatic congestion and centrilolular cell necrosis and jaundice. Ninety percent of theincrease in serum bilirubin was due to a rise in unconjugated bilirubin on the first postoperative day. Preoperative TB concentration and preoperative high right atrial pressure were the factorsassociated with increased risk of postoperative hyper bilirubinemiaby logistic regression analysis. The incidence of postoperative jaundice in our study was much lower than others study. The high incidence of postoperative jaundice in Abha study related to prolonged pump time in comparison to shorter pump time in our study.13 In Collins et al14 study hypotension, hypoxia, hemolysis, heart failure and hypothermia were not associated with the development of post operative jaundice, although post operative jaundice was significantly associated with multiple valve replacement, higher transfusion requirements, and longer CPB. We believe that excretion of bilirubin related to hepatocyte normal function, and, occurrences of centrilolular cell necrosis exacerbates postoperative hepatocyte dysfunction Jakob et al15 hypothesized that increasing pump flow during hypothermic CPB would improve organ perfusion and reduce the inflammatory response in the post-operative period. In our study, type of CPB has not any influence on the post operative LFT. This is one of the important limitations of our study, because we have not included complex and combined surgery in our study, and short pump time and cross clamp time would not reveals, effect of specific pump type on blood cell components. Strict exclusion criteria have been set in our study in order to exclude patients with known liver function test abnormality, or any other condition, which could affect hepatic enzymes postoperatively such as chronic obstructive pulmonary disease COPD. The patients with severe COPD have some degree of right ventricular (RV) failure. RV failure caused hepatic congestion and exacerbates effect of CPB and intraoperative hypotension on liver function test. This conflict was not considered in inclusion criteria in previously mentioned studies.16 Our results showed a statistically significant increase of total bilirubin and decrease of indirect bilirubin. Transferees enzymes were also significantly increased . Dancona et al.17 have shown that in some patients, CPB caused hypo perfusion. Effects of hypo perfusion and hypoxia on intestinal cells lead to activation of hepatic macrophages. Consecutive releases of mediators by macrophages lead to the development of jaundice and multiple organ failure. Vazquez et al18 demonstrated predicting factors in shocked liver and right heart failure following CPB include: hypotension, hypoxia, hypothermia and liver congestion. In these circumstances liver cannot handle the bilirubin load presented by massive transfusions. Transient postoperative high hepatic enzymes levels also may be seen in massive transfusion associated with low cardiac output. Prolonged low cardiac output, which may compromise the hepatic blood flow, caused alterations in the microcirculation.21 We believe that there are two type of CPB induced hepatic failure. In type І, centrilolular and sinusoidal cell necrosis caused hypotension or shocked liver syndrome. In this condition, the patients may or not have acute renal failure but definitely have not end organ vasculitis. In type 2, there are generalized end organ vasculitis such as acral part vasculitis, that caused fingers and toes hypo perfusion and renal, brain or hepatic micro vascular involvement and leads to acute renal failure, encephalopathy and liver failure. The second type of CPB-induced vasculitis is very rare and in our knowledge careful literature review revealed few documented cases. Ohri and Velissaris22 demonstrated that administration of inotropic drugs further depresses portal vein flow while hepatic artery flow increases slightly. The net effect is a further decrease in total hepatic blood flow. Hessel23 also proposed that CPB induced hypotension or postoperative low cardiac output causes splanchnic venous spasm. Sanderson et al24 demonstrated that during CPB, total blood flow has been shown to decrease by approximately 20% and hepatic arterial blood flow by 20% to 45%. Olsson et al25 and Collins et al14 stated that CPB-induced hepatic dysfunction may interfere withliver scavenger function for gut derived bacteria and cytokines, leading to endotoxinemia andsepticemia an important risk factor for systemic inflammatoryresponse syndrome and subsequent multiple organ failure. The incidence of postoperativehyperbilirubinemia in Faust and Reddy 26 study was 35.1%, opposed to 7% in our study. Despite progress in technology of oxygenators, techniques of surgery,CPB, and cardiac anesthesia in the last decades variability in incidence of post operative jaundice related to surgeon experiences likes short pump time.28 In our study, mortality of thepatients with CPB induced jaundice was 15%, opposed to only 5.6% in other study.27 In the Collins et al14 study the serum totalbilirubin concentration, mainly resulting from increased conjugatedbilirubin, which reached a maximum level on the second postoperativeday. Collins et al14 supposed that this single serum total bilirubin measurementon the second postoperative day could identify patients at highrisk for mortality in the postoperative period. In our study, the serum total bilirubin reached its maximum level on the first, second and third postoperative day in 40%, 50%, and 10% of the patients successively, and increased serumtotal bilirubin came mainly from unconjugated bilirubin. Thecorrelation of postoperative hyperbilirubinemia with higherpostoperative mortality was also noted in our study. The mortality of patients are related to the time of postoperative jaundice occurence28 and was significantly increased in patients whose total bilirubin concentrationreached to its peak level on the seventh postoperative day.The mortality is lowerin the patients whose total bilirubin concentration increased topeak level on the first and second post operative day. In our study the mortality was higher when peak postoperative jaundice reached to peak level on the third postoperative day. Nature of the hyperbilirubinemia, would determine the course and mortality of CPB-induced jaundice. Collins et al14 supposed that failure of thecanalicular excretion of bilirubin was the main causeof this conjugated hyperbilirubinemia. In contrast to previous study, postoperative hyperbilirubinemiacomes mainly from an increase of unconjugated bilirubin withhemolytic origin in 50 patients who underwent cardiac operations in our study.In Klepetko and Miholic study,29 70% of the increase intotal bilirubin after operation comes primarily from unconjugated bilirubin. Chu et al30 stated that significant decrease of haptoglobin concentrationwith lactate dehydrogenises increasing immediately after operations suggests thatpostoperative hyperbilirubinemia is caused by an unconjugatedbilirubin load. Mathie27 stated that mechanisms underlying the development of late postoperativehyperbilirubinemia differ from those of the earlypeak total bilirubin level. They supposed that immediate occurrence and rapid decline of postoperativehyperbilirubinemia related both to hepatic canalicular failure for disposing bilirubin and in other hand, may reflectthe transient damaging effects on the blood elements whereas steady increase of the total bilirubin levelto reach its peak on the seventh day, mainly conjugated bilirubin,was a consequence of hepatic dysfunction caused by factors such as Centrilobular cell necrosis, hepatic congestion, right or bi ventricular cardiac failure.32The pathogenesis of liver dysfunction after cardiac surgery is multi-factorial. Varghese et alotension . Braun eion time . LaupaciWe extend our sincere appreciation to the efforts taken by thestaff of the Department of Cardiovascular Surgeryin Imam Ali hospital that without whose efforts we would not have been able to completethis project.The study was approved by the Local Ethics Committee.Authors declare no conflict of interest in this study.


P = 0.34), subjective satisfaction , time to return to work , hand grip and pinch strength, and the operative time  between patients in the ECTR and OCTR groups . The rate of hand pain  in the ECTR group was significantly lower than that in the OCTR group. ECTR treatment seemed to cause more reversible postoperative nerve injuries as compared with OCTR . Although ECTR significantly reduced postoperative hand pain, it increased the possibility of reversible postoperative nerve injury in patients with idiopathic CTS. No statistical difference in the overall complication rate, subjective satisfaction, the time to return to work, postoperative grip and pinch strength, and operative time was observed between the two groups of patients.The objective of this study is to do a meta-analysis of the literature and compare the safety and efficacy of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) for idiopathic carpal tunnel syndrome (CTS). A comprehensive literature search of the electronic databases MEDLINE, EMBASE, Google Scholar, and the Cochrane Controlled Trial Register was undertaken for randomized studies reporting carpal tunnel syndrome treated with ECTR or OCTR. The quality of randomized trials was critically assessed. Pooled relative risk (RR) and 95% confidence intervals (CIs) for safety and efficacy outcome variables were calculated by fixed-effect or random-effect methods with RevMan v.5.1 provided by the Cochrane Collaboration. A total of 13 randomized trials were included by total retrieve and riddling. The results of our meta-analysis showed no significant difference in the overall complication rate (RR = 1.34, 95% CI ,  Carpal tunnel syndrome (CTS) is one of the most common causes of neuropathy in the upper extremities. It occurs most often in patients aged 30 to 60 years and is two- to threefold more common in women than in men . In manySince Phalen et al.  developeThere is no generally accepted consensus for proper surgical management of idiopathic CTS with respect to the efficacy and safety of ECTR and OCTR, especially concerning complications including nerve, vascular, and tendon injuries and wound infections; postoperative hand function; and return to work. The aim of the present meta-analysis was to validate the efficacy and safety of the selection of clinical treatment for such patients. We hypothesize that ECTR may help CTS patients return to work quicker than OCTR; patients with both surgical techniques may present similar postoperative hand function and complication.A systematic literature search was performed to identify randomized controlled studies that assessed the efficacy and safety of ECTR and OCTR treatment for idiopathic CTS. The results were systematically analyzed to determine the relationship between the treatment method and the surgical outcome in carpal tunnel syndrome patients.Studies that reported information pertaining to the efficacy and safety of ECTR and/or OCTR treatment for idiopathic CTS were retrieved, including (1) randomized controlled trials that compared ECTR  and OCTR  in idiopathic CTS; (2) studies in which all patients were diagnosed with idopathic CTS; (3) studies that reported follow-ups longer than 4 weeks; and (4) studies that were published in or previously translated into the English language. Studies were excluded if they included patients with arthritis, diabetes, thyroid disease, pregnancy, and any traumatic or operation history of the wrist.Electronic searches were performed using the electronic databases provided by Google Scholar [1966 to September 2013], MEDLINE [1966 to September 2013], EMBASE [1974 to September 2013], and the Cochrane Controlled Trial Register [Cochrane Library 2013]. Two independent researchers (Zuo and Wang) conducted literature searches using the search keywords “carpal tunnel release”, “endoscopic”, “open”, “versus or Vs”, and “Randomized or randomization”, with various combinations of the operators “AND”, “NOT”, and “OR”.Eligible studies were evaluated for inclusion by two independent reviewers, and the level of agreement between the reviewers was recorded. Inclusion of resultant titles was determined by manual screening of the titles and abstracts, followed by full-text screening by the same reviewers. Two reviewers independently assessed risk of bias (ROB) of randomized controlled trials (RCTs) and methodological quality of systematic reviews using the 12 validity criteria  of the CThe Cochrane ROB tool addresses threats to several internal validity domains . The ROB for performance, detection, and attrition was assessed for a priori defined groups of objective and subjective outcomes separately and was classified as high, low, or unclear. Afterwards, for each RCT, within-study summary ROB rating was derived for subjective and objective outcomes. At data synthesis stage (evidence grading), the across-study average summary ROB was determined and assigned to each outcome of interest.Two reviewers assessed the quality of the studies included independently, and the revised Jadad scale  was usedPatient outcome measurement included complications, operative time, postoperative subjective satisfaction in at least 12 weeks after surgery, hand pain rate 12 weeks after surgery, hand grip and pinch strength, and the time to return to work. Complications were considered as primary outcome, and other outcomes were secondary. (1) Complications referred to any nerve or muscle tendon injury, hematoma, wound infection, or dehiscence after surgery. (2) Subjective satisfaction referred to patient satisfaction with the surgical outcome at postoperative visits 12 weeks after surgery. (3) Hand pain referred to patient complaint of scar tenderness or pillar pain as assessed by the visual analogue score (VAS) ranging from 0 to 10 points, where a VAS score >3 was analyzed in the study. (4) Hand grip and pinch strength referred to hand grip and pinch strength 12 weeks after surgery as assessed by the equipment and measured in kilograms. (5) Operative time referred to the time from tourniquet inflation to wound suture. (6) Time to return to work referred to the first day after surgery to the time of returning to work.Q test with a P value equal to 0.1. The I2 (variability) statistic is the percentage of total variation across studies due to heterogeneity. A random-effect model was used for heterogeneous data, and sensitivity analysis was conducted to predict the potential source of heterogeneity; otherwise, a fixed-effect model was used. Meta-analysis of pooled relative risk was performed. P values less than 0.05 were considered statistically significant (P < 0.05).All data were analyzed using RevMan v.5.1 software . Relative risk (RR) and 95% confidence intervals (CIs) were reported. Heterogeneity between studies was assessed using Cochrane’s Initial electronic database searches yielded 1,266 relevant titles, of which 1,250 were excluded due to failure to meet the inclusion criteria. The remaining 16 articles were subjected to full-text review, resulting in exclusion of two additional articles due to failure to meet the inclusion criteria, mostly due to inappropriate comparison methods . One ranThe 13 included randomized controlled studies reported a total of 1,315 hands with idiopathic CTSs treated with either ECTR or other OCTR methodologies. The follow-up period for each study ranged from 1 to 52 months. Publication dates ranged from March 1992 to January 2013. ECTR treatment was administered in 688 hands, and the remaining 627 hands underwent OCTR. Patient demographics, follow-ups, and patient characteristics of the 1,315 hands are listed in Table Overall, eight RCTs reported an adequate method for random sequence generation (low ROB). Only five RCTs (5/13) had lower risks of detection bias for outcomes. Most RCTs failed to report the blinding status of patients, study personnel, and/or outcome assessors. Attrition bias was judged at low risk for at least 11 RCTs. All RCTs were at low risk of selective reporting of outcome. See the ROB assessment for the included RCTs Figure .Figure 2All the 13 clinical trials were level-II evidence. For the 12 ROB criteria by Fulan 2009, studies included in the current meta-analysis presented a high evidence level (at least six criteria for each study). For the revised Jadad scale, only two studies had 3 points, indicating a relatively poor quality, and the other studies had 4–7 points, indicating a high quality. The detailed Jadad score of 14 studies is shown in Table I2) in the results of the six studies used to compare operative time between ECTR and OCTR patients demonstrated a true difference in the treatment effect of 97%, indicating heterogeneity; therefore, the random-effect model was used to adjust for comparison of heterogeneity. The study by Sennwald [I2 of 87%). The I2 value in three studies [I2 value of four included studies was 44%, indicating a heterogeneity; sensitivity analysis was employed and found the study of Dumontier et al. [I2 value was 0%). The heterogeneity Q test in comparing patient hand grip strength, time to return to work, reversible nerve injury, and the overall complication rate exhibited no heterogeneity, and therefore, the random-effect model was used.The variability ).Complete data for the complication rate were available in all included studies, allowing for use of all 13 studies in the analysis of the overall complication rate. Postoperative nerve injury was mentioned in eight studies ,26,22,7.Z = 0.96; P = 0.34) as compared with OCTR patients. Noticeably, the complication risk was higher in two-portal ECTR patients than in one-portal ECTR patients . The forest plot of overall complication and subgroup analysis is shown in Figure The overall complication rate did not differ significantly between the ECTR and OCTR groups either in the overall or subgroup related to the comparison of endoscopic technique. The ECTR patients exhibited no significant difference in complication rate . The forest plot showing the comparison of operative time of five studies is shown in Figure Six studies ,23,25-27Z = 0.09 (P = 0.92)), as compared with patients in the OCTR group. Detailed information is shown in Figure Four studies ,22,28,24P = 0.16) for grip strength and −0.53  for pinch strength, indicating that the two outcomes did not favor the carpal tunnel release technique specifically. Comparison of hand function 12 weeks after surgery is shown in Figures Two studies ,20, inclZ = 2.43 (P = 0.02)) as compared with OCTR patients. Sensitivity analysis was performed by eliminating the study of Dumontier et al. [Four studies ,21,20,7,Z = 1.49 (P = 0.14)). Comparison of time to return to work is shown in Figure Two studies ,28 evaluTo provide an accurate and contemporary analysis on carpal tunnel syndrome treatment, the current meta-analysis reviewed 13 methodologically sound randomized controlled studies encompassing 1,315 idiopathic CTS hands treated with OCTR or ECTR. The results clearly indicated that ECTR significantly increased the risk of reversible postoperative nerve injury as compared with OCTR, while the operative time, postoperative overall complication incidence, and hand function were not significantly different between the two groups of patients 3 months after surgery. Despite extensive recent investigation of carpal tunnel release and different surgical procedures for CTS patients, no consensus for proper treatment has been widely accepted. Thus, the current study provides a novel and compelling evidence for contemporary clinical practice for idiopathic CTS patients.P = 0.34); the conclusion about nerve injury risk in the current study was similar to that in Thoma et al.’s study. The subgroup analysis regarding different endoscopic techniques  was consistent with the overall complication risk between ECTR and OCTR, although patients who underwent the two-portal endoscopic technique displayed a slightly higher susceptibility to complication risk .Many efforts have been made to prove the advantages of endoscopic release over open carpal tunnel release treatment option for idiopathic CTS ,12,4,27.P = 0.35) as compared with OCTR patients. However, it is worth mentioning that the setup of ECTR instruments requires additional time after anesthesia and the setup time was not described qualitatively, thus possibly contributing to the uncertainty of this analysis. Subgroup analysis was not conducted owing to the relatively small sample. The recent conflicting evidence is mainly attributable to methodological discrepancies and different measurement methods between studies. Regarding pain relief, ECTR patients reported significantly less pain during the follow-up interview 12 weeks after surgery (P < 0.0001) compared with OCTR patients. Several studies employed VAS (0–10 points) to quantify the pain complaint of patients, thus minimizing the subjective influence on the assessment. But only few data related to the meta-analysis can be retrieved from the published results. In the study by Atroshi et al. [The evidence from this meta-analysis supports the conclusion that ECTR reduced the incidence of hand pain, while no significant difference was found in operative time as indicated by the follow-up visits 12 weeks after surgery. In the current study, only six studies ,25,23,26i et al. , the difP = 0.05). Trumble et al. [P = 0.0086). Pooled data in the current meta-analysis reach agreement with the findings of Brown et al. [P = 0.14), who reported valid grip and pinch strength 12 weeks after surgery. There was no statistically significant difference in hand grip and pinch strength between the ECTR and OCTR groups. Several studies [Better hand function recovery promotes early return to work in patients receiving ECTR or OCTR. In a randomized trial by Brown et al.  who evale et al.  reportedn et al.  and Trumn et al.   and OCTR  techniques in outcome variables except for complications, mainly due to the insufficient sample size and limited available data. Third, studies included in the current meta-analysis by Ferdinand et al. , Wong etIn summary, the current study included the pooled data from, to the best of our knowledge, the largest study sample involving 1,315 hands of patients having idiopathic carpal tunnel syndrome in 13 randomized controlled studies. The results reported in the contemporary medical literature showed that although ECTR significantly reduced postoperative hand pain, it increased the possibility of reversible postoperative nerve injury in patients with idiopathic CTS. No statistical difference in the overall complication rate, subjective satisfaction, the time to return to work, postoperative grip and pinch strength, and operative time was observed between the two groups of patients.


Nasturtium nasturtium) is a medical plant containing diverse chemically-active substances with biological properties. The present study was conducted to investigate the immunomodulatory effects of watercress extract on immunological and hematological parameters of rainbow trout (Oncorhynchus mykiss). Fish were fed for 21 days with diet supplemented with 0.1% and 1% of watercress extract per 1 kg food and with a normal diet as control. Hematological parameters such as red blood cells (RBC) and white blood cells (WBC), hematocrit (Hct), hemoglobin (Hb), RBC index like mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) as well as immunological parameters such as peroxidase, lysozyme and complement activities, total protein, albumin and globulin levels were measured after 21 days of watercress extract treatment. The results indicated that oral administration of 1 % watercress extract in fish may enhance some hematological and immunological parameters including Hb and MCHC, lysozyme and complement activities, total protein and globulin levels, compared to the controls after 21 days of experimental period. In conclusion, on the basis of these results, oral administration of watercress extract may be useful to improve fish’s immune system.Watercress ( Although the application of antibiotics and chemicals can be effective in controlling pathogens in aquatic animal farms, the residues of these compounds in meat may be a threat to the health of consumers .Many scientists believe that the word consumption of medical plants is growing rapidly . In fact, most research has focused on the role of plant extracts in stimulating the immune system in fish comparing with bacterial, parasitic and fungal agents .Recently, several efforts have been made to replace chemical drugs by herbal medicine in aquaculture industry in many countries  is a perennial plant which growths in clear, cold water and is found in ditches and streams everywhere.Nevertheless, there are concerns and doubts about the use of herbal medicine and their derivatives as alternative drugs . These studies did not investigate the impact of herbal drugs on health status of the fish. Therefore, our knowledge about usage of commercial herbal medicine in aquaculture is very limited. Thus, research on the effects of these compounds before administration is necessary. Watercress , oxidative stress , asthma , scorch  and immune depression . Raw watercress leaves are used as salad greens, or can be steamed and consumed as a normal processed vegetable.Watercress, which is cultivated for its pungent leaves which are used in cooking especially in soups, garnishes and salads, is one of the most important herbal medicines used in traditional treatment of some diseases such as diabetes . The active constituents of watercress (Nasturtium nasturtium) extract may strengthen or stimulate the immune response by interacting with various parameters of the immune system.Watercress is a valuable source of vitamins and a good detoxifying herb. This plant contains a relatively large amount of vitamins B1, B2, C and pro-vitamin A, folic acid, glucosinolates, iodine, iron, protein, and especially calcium and sulphur compounds, which influence its characteristic odor, but also adds to its nutritional benefits  and through triggering phase II enzymes such as quinine reductase (quinine-acceptor), oxidoreductase, glutathione -S- transferase (GST) and glucuronosyltransferases, resulting ultimately in the excretion of potential carcinogens . In addition, administration of watercress extract can inhibit of fibrosis , inhibit of inflammation , inhibit of P450 activity  and have antioxidant properties and inhibit of lipid peroxidation .According to published research findings, watercress is the richest source of glucosinolates, which can be hydrolyzed to produce phenethyl isothiocyanate. Isothiocyanates can prevent carcinogen activation through the inhibition of phase I enzymes, such as cytochrome P 450s  stated that one way to distinguish the appropriate or inappropriate prescription of medical plants is the assessment of their effects on hematological and biochemical parameters in experimental animals. Although the effect of oral administration of watercress on hematological and immunological parameters in experimental animals was previously studied, there is not any information about the impact of using watercress extract on different parameters of immune system of fish.Based on scientific findings, Kolawole Measuring the alterations in innate immunity and non-specific immune parameters of treated fish with herbal derivatives is one way to evaluate the effects of herbal drugs on immune system of fish. Therefore, the aim of the present study is to assay the effect of watercress oral supplement on some non-specific immune parameters of rainbow trout.Oncorhynchus mykiss, average weight 96±10 g, and average length 14±2 cm) were purchased from a private farm  and were transferred to another private farm . After transport, fish were randomly parceled in nine closed water recirculating systems (1000 L) for at least two weeks to acclimate to the laboratory conditions  prior to experiments. During acclimation, fish were fed with commercial diets (Behparvar Co. Iran) at 2% of their body weight twice a day.Juvenile rainbow trout . In this method, watercress leaves were extracted with chloroform–methanol  in a warming blender. This extract was dried over anhydrous sodium sulfate, and the solvent was removed from the filtrate under reduced pressure at 45°C.During experimental period, the fish were fed for 21 days with 0.1 and 1% watercress extract per 1 kg food, and commercial diet only as controls, to examine the effect on immune parameters. The watercress was collected from the bank of Gav River  and the extracts were prepared according to procedure described by Banaee Watercress extracts were then mixed with commercial diets . Fish from each experimental and control groups were bled from the dorsal aorta into sterilized glass vials at 4 °C containing the anticoagulant ethylene glycol tetra-acetic acid (EDTA) at 1%.Immunostimulatory activity was evaluated after the 21The blood was centrifuged for 15 min at 4000 g, 4ºC. Plasma were immediately stored at -80ºC until biochemistry and immunostimulatory activity analysis.-2 and 10-3 in phosphate-buffered saline (PBS) at pH 7.2 . Hematocrit (Hct) was determined by the microhematocrit method described by Brown (1988). Hemoglobin (Hb) concentration was conducted by using the cyanohaemoglobin method . Red cell indices, mean corpuscular volume , mean corpuscular hemoglobin , and mean corpuscular hemoglobin concentration  were calculated from RBC, Ht, and Hb according to Banaee et al. (2008) as follows:The blood was immediately used to determine the number of red blood cells (RBC) and white blood cells (WBC) by means of a haemocytometer slide at a magnification of 400X. Thus, blood was diluted to 108 cell/ml in EDTA-magnesium-gelatin veronal buffer (0.01 M). Precisely 100 μl of the RaRBC suspension was lysed with 3.4 ml of distilled water and the absorbance of the haemolysate was measured at 414 nm against distilled water to acquire the 100% lysis value.Alternative complement activity (ACH50) was evaluated following the procedure of Yano (1992) by using rabbit red blood cells (RaRBC). Briefly, RaRBC were washed and adjusted to 2 × 10xg for 10 min at 4ºC. The absorbance (A) of supernatant was measured using a spectrophotometer at 414 nm. A lysis curve was obtained by plotting the percentage of haemolysis against the volume of plasma added. The volume of plasma producing 50% haemolysis (ACH50) was determined and the number of ACH50 units/ml was obtained for each fish.The test plasma was appropriately diluted, and different volumes ranging from 0.1 to 0.25 ml were made up to 0.25 ml total volume before being allowed to react with 0.1 ml of RaRBC in test tubes. After incubation at 20ºC for 90 min with occasional shaking, 3.15 ml of a 0.9% (w/v) saline solution was added to each tube with centrifugation at 1600 et al. (2001) with minor modifications. Thus, plasma (50 µl) was added to 2 ml of a suspension of Micrococcus lysodeikticus (0.2 mg/ml) in a 0.05 M sodium phosphate buffer (pH 6.2). The reaction was carried out at 25ºC and absorbance was measured spectrophotometrically at 570 nm after 0.5 min and 4.5 min. PBS was used as a blank. A unit of lysozyme activity was defined as the sample amount causing a decrease in absorbance of 0.001/min. Lysozyme of sample calibrated using a standard curve determined with hen’s egg white lysozyme (Sigma) in PBS.The turbidimetric assay for lysozyme was carried out according to Lange et al. (2007). Briefly, 10 µl of plasma was diluted in 100 µl of Hank’s balanced salt solution (HBSS) buffer. Then, 50 µl of 20mM 3,3’,5,5’–tetramethylbenzidine hydrochloride and 2.5 mM hydrogen peroxide were added. The color change reaction was stopped after 2 min by adding 50 µl of 2M sulphoric acid and the optic density was read at 450 nm. Standard samples without plasma were also analyzed. The peroxidase activity (unit/ml plasma) was determined defining one unit of peroxidase as that which produces an absorbance change of 1 OD.The total peroxidase content in plasma was measured according to the method used by Cuesta Plasma total protein and albumin levels were measured by using the total protein and albumin kit (Parsazma Co. Iran). Globulin levels were calculated by subtracting albumin values from plasma total protein.Statistical analyses were performed using SPSS (Release 15) software. Data are presented as mean ± SD. All the data were tested for normality (Kolmogorov-Smirnov test). Data were analyzed by one-way of variance analysis (ANOVA). The significant means were compared by Tukey’s test and a p < 0.05 was considered statistically significant.No significant differences were observed in the final weight, final length, weight gain, specific growth rate (SGR) and food convert ratio (FCR), among different experimental groups and these groups and the control group .st day. Hb concentrations were significantly increased when fish were treated with diets enriched with 1% of watercress extract per 1 kg food on the 21st day when compared to control (p < 0.05). MCHC value of fish fed with 1% of watercress extract per 1 kg food was significantly higher than its value in the control group on 21st day . No significant changes in albumin levels in plasma of fish fed with watercress extract-enriched food when compared with control group (P<0.05). Consumption of food containing 1% of watercress extract had a significant effect on globulin concentrations in plasma of experimental fish after 21 days  on hematological and immunological parameters of rainbow trout (Oncorhynchus mykiss).The present study focused on the immunostimulantory properties of watercress extract containing a relatively large amount of vitamins B1, B2, C and pro-vitamin A, folic acid, glucosinolates, iodine, protein, iron, calcium and sulphur compounds .Although, the results obtained in this study show that oral administration of the watercress extract had no significant effect on growth rate of experimental fish, some recent studies have shown that feeding herbal supplementary food to fish resulted in increased disease resistance and in improved survival and growth rate, which may be attributed to an improvement of immune functions . Although our results suggest that while oral administration of 1% watercress extract for at least 21 days may increase hemoglobin content (Hb) and MCHC values, no significant alternations were observed in the number of erythrocytes and leukocytes as well as hematocrit, MCV and MCH values. In other words, oral administration of watercress extract may concentrate hemoglobin in red blood cells of fish. Increase in hemoglobin content (Hb), hematocrit, and numbers of leucocytes and thrombocyte were reported in Nile tilapia  and hybrid tilapia  fed with diet enriched by garlic. These results were in agreement with previous findings where feeding with other herbal supplementary food led to an increase in hemoglobin levels .Hematology, including erythrocyte count, haemoglobin concentration, haematocrit and leucocyte count, has provided valuable information for fishery biologists in the assessment of fish health  reported increase in lysozyme activities of Nile tilapia (Oreochromis niloticus) fed for seven days with Chinese herbs Astragalus membranaceus and Lonicera japonica. Furthermore, according to scholar’s reports, the use of Astragalus radix , Eclipta alba , Ganoderma lucidum  incorporated into the fish diet and fed for 14 to 60 days led to a significant increase in the lysozyme activity.Lysozymes are a family of enzymes with antibacterial activity characterized by the ability to damage the cell wall of bacteria. So, significant increase in lysozyme activity in plasma of fish fed for 21 days with diet enriched with 1% of watercress extract may indicate an increase the fish’s immune system defense against bacterial agents. Yet, feeding with 0.1% of watercress extract did not reveal a significant difference in lysozyme activity relative to the controls. Ardó Complement includes over 20 different plasma proteins that are produced by a variety of cells including, hepatocytes, macrophages and gut epithelial cells. Some complement proteins bind to immunoglobulins or to membrane components of cells. The complement system is an essential and effective part of the innate immune system. It can rapidly distinguish and opsonize bacteria for phagocytosis by specialized phagocytes or destroy them directly by membrane disorder .et al., 2007), sodium alginate , and vitamins C and E .The enhancement of complement activity (ACH50) in plasma of fish fed with diet enriched with 1% of watercress extract may indicate the improvement of the fish immune system ability during experimental period. Thus, the increase of the complement activity (ACH50) in plasma of fish may help to identify and eliminate bacterial agents by phagocytosis. Therefore, the increased total protein levels in plasma of fish treated with watercress extract is accompanied by the increased levels of immune parameters which have a protein structure, such as globulins and total complements. Several authors reported an increase in complement activity following administration of different immunostimulants such as herbal derivatives . Based on results, oral administration of watercress extract did not significantly affect peroxidase activity in plasma of fish when compared with control group at the end of experimental period.et al. (2007) recorded an increase in myeloperoxidase activity in tilapia fed with diets supplemented with different levels of aqueous extract of Eclipta alba for 1 week, whereas they didn’t reported any significant changes in myeloperoxidase activity after two or three weeks.Christybapita In the present study, the enhancement of total protein by using 1% of watercress extract supplementary food has been widely observed in fish. Since, there is a close relationship between the level of protein synthesis in liver tissue and plasma protein pools, total protein levels in plasma may be elevated due to the increased levels of protein synthesis in liver tissue of fish treated with watercress extract.et al. (2011) reported that oral administration of some herbal medicine such as silymarin may improve protein synthesis in fish liver tissue. Consequently, significant increase of the total protein levels in plasma in treated fish is probably reflecting the increase of the protein synthesis in liver tissue. Similarly, the highest serum protein level was recorded in Nile tilapia fed yellow leader and Japanese honeysuckle , ginger, mistletoe and stinging nettle . Proteins include albumin and globulin; some globulins are produced in the liver, while others are made by the immune system . Globulin is made up of subunit of α1, α2, β, and γ globulins, which are considered as the source of almost all the immunologically active proteins in the blood . Commonly, increases in the levels of plasma total protein, albumin and globulin in fish are thought to be associated with a stronger innate immune response .Banaee Although albumin did not increase in most of the treatment groups in the present study, globulin responded similarly to total protein, which certainly increased. Since albumin plays an important role in transport of some compounds such as drug in blood, minor increase albumin levels in plasma of experimental fish may help to transport of watercress extract in blood. Therefore, the increase of globulins in plasma of fish treated by 1% of watercress extract may indicate enhanced immune system of fish.In conclusion, the results indicated that the use 1% of watercress extract as an immunostimulant in fish diets may have led to enhanced fish immunity. Since the watercress is rich in vitamin C, the increase of Hb and MCHC indicate that oral administration of the watercress extract dietary supplements can be effective in concentration of hemoglobin in erythrocyte of fish.


Globally, countries are increasingly prioritizing the reduction of health inequalities and provision of universal health coverage. While national benchmarking has become more common, such work at subnational levels is rare. The timely and rigorous measurement of local levels and trends in key health interventions and outcomes is vital to identifying areas of progress and detecting early signs of stalled or declining health system performance. Previous studies have yet to provide a comprehensive assessment of Uganda’s maternal and child health (MCH) landscape at the subnational level.By triangulating a number of different data sources – population censuses, household surveys, and administrative data – we generated regional estimates of 27 key MCH outcomes, interventions, and socioeconomic indicators from 1990 to 2011. After calculating source-specific estimates of intervention coverage, we used a two-step statistical model involving a mixed-effects linear model as an input to Gaussian process regression to produce regional-level trends. We also generated national-level estimates and constructed an indicator of overall intervention coverage based on the average of 11 high-priority interventions.National estimates often veiled large differences in coverage levels and trends across Uganda’s regions. Under-5 mortality declined dramatically, from 163 deaths per 1,000 live births in 1990 to 85 deaths per 1,000 live births in 2011, but a large gap between Kampala and the rest of the country persisted. Uganda rapidly scaled up a subset of interventions across regions, including household ownership of insecticide-treated nets, receipt of artemisinin-based combination therapies among children under 5, and pentavalent immunization. Conversely, most regions saw minimal increases, if not actual declines, in the coverage of indicators that required multiple contacts with the health system, such as four or more antenatal care visits, three doses of oral polio vaccine, and two doses of intermittent preventive therapy during pregnancy. Some of the regions with the lowest levels of overall intervention coverage in 1990, such as North and West Nile, saw marked progress by 2011; nonetheless, sizeable disparities remained between Kampala and the rest of the country. Countrywide, overall coverage increased from 40 % in 1990 to 64 % in 2011, but coverage in 2011 ranged from 57 % to 70 % across regions.The MCH landscape in Uganda has, for the most part, improved between 1990 and 2011. Subnational benchmarking quantified the persistence of geographic health inequalities and identified regions in need of additional health systems strengthening. The tracking and analysis of subnational health trends should be conducted regularly to better guide policy decisions and strengthen responsiveness to local health needs.The online version of this article (doi:10.1186/s12916-015-0518-x) contains supplementary material, which is available to authorized users. The measurement of population health outcomes and intervention coverage is a vital component of evaluating health systems performance . The allUganda has made marked progress in reducing under-5 mortality since 1990, which declined from 163 deaths per 1,000 live births in 1990 to 85 deaths per 1,000 live births in 2013 . While UOver the last two decades, Uganda’s government has prioritized expanding health services across a number of key maternal and child health (MCH) interventions. Since 2002, distribution of insecticide-treated nets (ITNs) has substantially expanded , indoor To date, few studies have benchmarked health systems performance at the subnational level in low-income countries. Several studies have addressed inequalities in intervention coverage but are generally restricted to comparisons by sex, urbanicity, or socioeconomic status –13. OtheBy systematically collating all available data, this study provides a comprehensive regional assessment of a broad range of MCH indicators and socioeconomic factors in Uganda from 1990 to 2011.We identified data sources for MCH indicators via in-country meetings with collaborators and relevant stakeholders. For this analysis, we used 17 household surveys and two population censuses  delineated in the 2011 Demographic and Health Survey  only ascertained pentavalent and measles immunization status for children aged 0–24 months, and weight measurements were taken for children aged 6–59 months . In ordeq0i,t,s is under-5 mortality in region (i), year (t), as measured by source (s). The β terms are fixed effects; β0 and β1 are the global intercept and slope, respectively, and β2 is an adjustment coefficient included for non-DHS sources to account for an observed discrepancy between under-5 mortality estimates derived from DHS surveys and those derived from other surveys. All other terms are random effects. Specifically, ui and vi are a regional-level random intercept and slope, respectively, and are both assigned conditional autoregressive priors [wt is a year-level random intercept assigned a first-order random walk prior [δi,t is a region-year level random intercept with the prior given by the interaction between a conditional autoregressive prior for spatial trends and a first order random walk prior for temporal trends [γi,s is a source-year level random effect assigned an independent and identically distributed normal prior and is included to account for autocorrelation in estimates of under-5 mortality derived from the same source in the same region. Weakly informative normal priors were assigned to all fixed effects and weakly informative gamma priors were applied to the log precision of all random effects. To generate predictions from this model, we approximated the posterior distribution of θi,t by setting Is ∉ DHS and γi,s to 0. The median, 2.5th, and 97.5th percentiles of this distribution were inverse-logit transformed to generate the point estimates and confidence intervals (CIs) for 5q0i,t in each region and year.We adapted a previously described modeling and validation framework for modeling regional trends in under-5 mortality in Uganda . Specifie priors ; these tlk prior ; this tel trends . This raWe used a two-step modeling approach to generate regional trends from 1990 to 2011 for each indicator. In the first stage, we fit the following linear mixed-effects model with random intercepts and slopes for each region.i and year t. For modeling coverage estimates, which are bounded between 0 and 1, logit transformation was applied. On the other hand, for variables such as years of maternal education log transformation was used. We used a one-knot natural cubic spline with two basis functions (h1 and h2) to act as a smoother. The random effects  allow the levels and trends to vary between regions.Observations are indexed to region In the second step, the predicted trend from this linear model acts as the mean prior for Gaussian process regression (GPR), which is implemented with a Matern covariance function , 38. GPRWe created two overall intervention coverage metrics to summarize regional intervention levels. First, we estimated an overall intervention coverage metric that included 11 indicators spanning the spectrum of interventions included in this analysis: the proportion of households with IRS, ITN ownership or both; IPTp2; self-reported receipt of ACTs after fever; EBF; BCG, measles, OPV3, and pentavalent immunization coverage; ANC4; SBA; and the proportion of children who were not underweight. When constructing overall coverage metrics, prior theory-based judgments may be incorporated to reflect the relative value of interventions . For simAll analyses were conducted using Stata 13.1  and R version 3.0.1 . The model used for mortality estimation was fit using the INLA package .Permission to implement this research project was obtained from the Ministry of Health of Uganda. Ethical approval for this study was obtained from the institutional review board of the University of Washington, Uganda National Council of Science and Technology, and School of Medicine Research Ethics Committee. The study was conducted in compliance with national regulatory and ethics guidelines.We found large declines in under-5 mortality for all regions since 1990  in 1990 to 14 %  in 2011  and self-reported receipt of ACTs for febrile children under 5 increased to 49 % . Despite these gains, no region met the National Malaria Control Programme (NMCP) target of 85 % by 2010 for ITN ownership, under-5 ITN use, or IPTp2  in 1990 to 94 %  in 2011, and measles vaccination climbed from 63 %  to 85 %  during this time. In contrast, OPV3 coverage remained relatively unchanged across regions, increasing slightly from 1990 to 2000 and then somewhat declining since 2000. Pentavalent immunization coverage  reached comparable levels to OPV3 coverage in 2011  demonstrating a rapid scale-up since its introduction in 2002. At the regional level, immunization coverage was more varied. In 2011, OPV3 coverage ranged from 69 %  in Central 1 to 83 %  in Southwest, and pentavalent vaccination coverage spanned from 67 %  in East Central to 86 %  in Southwest. In general, Central 1 had lower levels of immunization coverage than the other regions, whereas Southwest had higher vaccination rates.Between 1990 and 2011, ANC1 coverage increased across regions, narrowing the gap between the regions with the highest and lowest levels of ANC1 over time Fig. . In 1990Uganda experienced a large increase in overall intervention coverage since 2000, which was largely driven by gains in coverage of malaria vector control (ITNs or IRS) and pentavalent immunization Fig. . In 2011This study represents the first comprehensive regional assessment of levels and trends of MCH indicators and socioeconomic factors in Uganda. All regions have achieved substantial progress in reducing under-5 mortality as well as scaling up coverage of malaria control interventions and pentavalent vaccination. At the same time, coverage of other key MCH interventions, such as OPV3 and ANC4, have generally flattened or declined over time. Analyzing regional trends revealed marked heterogeneity and geographic disparities in both coverage levels and outcomes, emphasizing the importance of routinely monitoring local health needs in a timely manner. Subnational benchmarking of health intervention coverage is a crucial step in identifying areas to which resources should be directed in Uganda and sub-Saharan Africa.Although under-5 mortality decreased throughout Uganda, geographic inequalities persisted, with Kampala consistently recording much lower rates of under-5 deaths than other regions from 1990 to 2011. Further, progress in reducing child mortality in Karamoja stalled after 2007, and its prevalence of childhood underweight was the highest in Uganda for 2011, more than 10 percentage points higher than the next-highest region. Although Karamoja achieved high levels of coverage for some interventions, particularly EBF and pentavalent vaccination, its health outcomes lagged behind other regions. Food insecurity due to climactic shocks, disease, and conflict is well-documented in this region –53, whicUganda’s trends along the maternal health continuum of care unveiled a number of notable findings. While all regions reached high levels of ANC1 coverage by 2011, trends for ANC4 coverage, which is recommended by Uganda’s national guidelines, were much more variable across regions . This coUganda has substantially increased coverage of malaria control interventions since 2000, reflecting investments in ITN distribution, subsidizing costs of ITNs and ACTs, and expanding IRS activities , 73, 74.Most regions had lower levels of IPTp2 coverage than ANC4, which suggests there is a substantial constraint to receiving IPTp at ANC visits as recommended by Uganda’s national guidelines . A natioImmunization progress has been variable in Uganda. Coverage of BCG and measles vaccination has increased markedly since 1990, while trends in polio and pentavalent coverage were more variable. The Reaching Every District approach promoted by the World Health Organization (WHO) sets a coverage target of 80 % for all districts in low- and middle-income countries in order to help rectify geographic inequities . While tThe quick rise of pentavalent vaccination coverage to similar levels as OPV3 in all regions demonstrates the successful implementation of the 2002 Gavi Vaccine Introduction Grant . This scThis study revealed substantial heterogeneity in health indicators and outcomes across Uganda’s regions. The decentralization of Uganda’s health system has emphasized management by local governance , which rOur findings need to be interpreted within the context of some study limitations. First, a number of relevant interventions could not be analyzed due to limited data availability. For instance, we were unable to obtain reliable data for HIV interventions such as prevention of mother-to-child transmission of HIV or pediatric HIV treatment. Second, several MCH indicators were limited by question comparability across surveys. Notably, questions concerning EBF only considered feeding in the day prior to the survey instead of in the first six months of life , and ACTUganda has experienced substantial declines in under-5 mortality and gains in ITN ownership and use, the receipt of ACTs, measles vaccination, ANC1, and SBA. However, progress in coverage of other indicators such as ANC4, IPTp2, and OPV3 has stalled. National level trends masked marked subnational heterogeneity, and further investigation is necessary to understand the drivers of regional variation. Enhancing the scope and reliability of health information systems would further enable the regular monitoring of levels and trends. Additional subnational benchmarking analyses, ideally at the administrative level where health services are delivered, should be conducted routinely in order to systematically guide resource allocation and policy decisions in Uganda and other countries in sub-Saharan Africa.


Carbon nanotubes (CNTs) are widely used in industry, but their environmental impacts on soil microbial communities are poorly known. In this paper, we compare the effect of both raw and acid treated or functionalized (fCNTs) multi-walled carbon nanotubes (MWCNTs) on soil bacterial communities, applying different concentrations of MWCNTs  to a soil microcosm system. Soil DNA was extracted at 0, 2 and 8 weeks and the V3 region of the 16S rRNA gene was PCR-amplified and sequenced using paired-end Illumina bar-coded sequencing. The results show that bacterial diversity was not affected by either type of MWCNT. However, overall soil bacterial community composition, as illustrated by NMDS, was affected only by fMWCNT at high concentrations. This effect, detectable at 2 weeks, remained equally strong by 8 weeks. In the case of fMWCNTs, overall changes in relative abundance of the dominant phyla were also found. The stronger effect of fMWCNTs could be explained by their intrinsically acidic nature, as the soil pH was lower at higher concentrations of fMWCNTs. Overall, this study suggests that fMWCNTs may at least temporarily alter microbial community composition on the timescale of at least weeks to months. It appears, by contrast, that raw MWCNTs do not affect soil microbial community composition. Carbon nanotubes (CNTs) are widely used in novel industrial materials because of their particular chemical and physical characteristics –3. They Global carbon nanotube production is increasing by around 25% per year and by 2015 is expected to reach 9300 tons with a production value of $1.3 billion . Neverthin vivo and in vitro, and has been related to various factors such as CNTs’ length, type of functionalization, concentration, duration of exposure, method of exposure, concentration of the solubilizing agent, and the surfactant used. So far, while many studies suggest that CNTs do not show toxicity, certain others suggest that CNTs are harmful to human health and the environment. These inconsistencies might be due to differences in experimental protocol [Despite their evident advantages in practical applications, the potential toxicity of CNTs is a major concern because of their potential impact in the environment . CNTs’ tprotocol .in situ [Escherichia coli to highly purified CNT aggregates can lead to cell death. In other studies, it has been shown that CNTs dispersed using a range of different surfactants can have antimicrobial properties when incubated with bacteria [Up to the present, few studies have investigated the impact of CNTs on living organisms in the environment ,25,26. Min situ ,29. For in situ , demonstbacteria ,31. It hbacteria ,33.Soil is likely to be one of the main ultimate recipients of nanomaterial contamination in the environment, more so than water and air ,26,34. SPrevious studies on CNTs in the soil system have been carried out by Chung et al.  who demoHere we set out to understand the effect of both treated (fMWCNTs) and untreated MWCNTs on soil bacterial communities at a range of taxonomic levels. We consider shifts in both relative abundance and diversity. The relative abundance of certain groups might be important because particular taxa are consistently associated with ecological functions in the soil, especially at the finer taxonomic level. Diversity may be important because it is widely thought that ecosystem resilience is affected by taxonomic diversity –40.Furthermore, we continued our experiment for 8 weeks; most other studies ran for less than 4 weeks ,32. GiveThat fMWCNTs will have a greater effect on soil bacteria than untreated MWCNTs, due to their greater ability to mix with soil water and interact directly with bacterial cells. This higher concentration of MWCNTs will also have stronger effects.That given the relatively slow and long-term nature of soil processes, including bacterial community shifts, the 8-week timeframe will show a different result from the much shorter 2–3 week timeframe used in most previous studies. The effect may intensify, as more cells die or are unable to reproduce under the effect of the MWCNTs.Essentially our hypotheses were as follows:In the present study, we use paired-end Illumina bar-coded sequencing of hypervariable V3 region of 16S rRNA gene to investigate the impact of multi-walled carbon nanotubes on soil bacteria.Soil samples were collected in June 2013 from an overgrown flowerbed on Seoul National University campus, which is located in the Gwanak Mountain area, south of Seoul. This sampling site was selected because it represents a typical and widespread type of soil (slightly acidic sandy loam) in South Korea. The upper 10 cm of soil was sieved and thoroughly mixed in a sterile container. The soil was divided into pots containing 200 g soil each. Soil pH was measured using a soil pH meter (Hanna Instruments HI 99121N Direct Soil pH Meter). Soil pH was around 6.1 and it contained 10.4% clay, 18.4% silt and 71.2% sand. Soil texture and organic matter content were measured at National Instrumentation Center for Environmental Management  following the standard protocol of SSSA (Soil Science Society of America).Pure commercial MWCNTs were purchased from Hanwha Nanotech, Republic of Korea. Two forms of CNTs were used in the present experiment: raw and functionalized forms of MWCNTs. The powder MWCNTs were not treated, but used in the form received from the purchaser because this is a form that microorganisms might encounter if there is an accidental release from a manufacturing facility. The functionalized MWCNTs are more commonly used during fabrication processes of commercial products, so would more likely be released at those sites .2SO4:HNO3 = 3:1 (v:v) were added to the raw MWCNTs at room temperature [The MWCNTs were functionalized (fMWCNTs), following the protocol described by Saito et al. , by attaperature . The mixperature . The MWCMWCNTs were characterized using Energy-Filtering transmission electron microscopy  and field-emission scanning electron microscopy . These techniques were effective in characterizing the internal structure  of MWCNTs. Raman spectra were taken to determine the diameter distribution using LabRam Aramis .The metal components in the MWCNTs are less than 5% in weight. They have been analyzed by the manufacturer  and are aluminum, iron, and molybdenum.The soil was divided into plastic self-draining pots containing 200 g soil each, to give 3 replicates to be exposed to each concentration of raw MWCNTs or fMWCNTs. The concentrations of MWCNTs applied to soil were 0 (DI water only), 50, 500, and 5000 μg/g soil. The soils were then well mixed to ensure homogeneity before incubation in a BOD incubator at 25°C for 8 weeks. The pots were not covered to allow free gas exchange to the soil microbial community. The positions of replicate pots of different treatments were randomized and randomly interchanged each week. Soil moisture was adjusted to 60% water holding capacity. Soil moisture content was maintained by weighing the pots twice a week and adjusting to initial weight by regular addition of DI water. Samples of 3 g of soil were collected from each pot, at different time points , to be used for DNA extraction. At T = 0 weeks, we took samples almost immediately (1 hour later) after adding MWCNTs to soil.5 = -XXXXXXXXGTACTCCTACGGGAGGCAGCAG-3 =) and 533R (5 = TTACCGCGGCTGCTGGCAC-3 =), targeting the V3 hypervariable regions of the bacterial 16S rRNA gene (the X sequence denotes a barcode sequence) [The soil DNA was extracted from 0.3 g of the mixed 3 g sample of soil, using the Power Soil DNA extraction kit  following the protocol described by the manufacturer. DNA isolated from each sample was amplified using primers 338F (equence) . The Polequence) .-2 to 10-7) of a plasmid containing a full-length copy of the Escherichia coli 16S rRNA gene, to estimate bacterial relative abundance. qPCR assays were conducted in 48-well plates. Each 10 μl reaction contained 5 μl of reaction mixture , 0.5 μl of forward and reverse primers (Eub 338 and Eub 518), and DNA-free water. PCR conditions were 2 min at 50°C, and 15 min at 95°C, followed by 40 cycles of 95°C for 60 s, 53°C for 30 s and 72°C for 45 s. Melting curve analyses was performed to confirm that the amplified products were of the appropriate size. Each plate included triplicate reactions per DNA sample.Relative abundance of bacterial subunit rRNA gene copies was quantified using quantitative PCR (qPCR). Standard curves were created using a 6-fold serial dilution  in mothur. To assess the relationship between soil bacteria richness/diversity and MWCNTs concentration, as well as with time incubation, the richness of OTUs and other diversity indices were calculated using the mothur platform [To perform the statistical analysis, all samples were standardized by random subsampling to 4,073 sequences per sample, using the sub.sample command  using the weighted UniFrac distance in Primer 6 to visualize the clustering of bacterial community composition over time. We then performed an analysis of similarity (ANOSIM) with pairwise weighted UniFrac distance as the response variable and MWCNTs concentration, time incubation and form as factors. We performed multiple regression analysis in R software package 2.15.2 using linear model (LM) for normal data, and a generalized linear model (GLM) for non-normal data to evaluate the effects of raw and functionalized MWCNTs concentrations, incubation time, and their interactions on bacterial richness and diversity, as well as on the relative abundance of dominant bacterial phyla. There were four different concentration treatments of raw and functionalized MWCNTs i.e. 0, 50, 500, and 5000 μg/g soil, and each treatment had three replicates. Aliquots of soil from each treatment were collected at different time points . To test whether bacterial abundance (qPCR) was correlated with fMWCNTs and raw MWCNTs across different sampling time, we performed regression analysis using linear functions in SigmaPlot. We used analysis of variance (ANOVA) to test the effect of fMWCNTs and raw MWCNTs on organic matter content of the soils.A total of 2,568,331 quality bacterial sequences were obtained from the 63 samples, with an average of 40,767 sequences per soil sample and with coverage ranging from 4,760 to 219,775 reads per sample .The characterization of MWCNTs based on FE-SEM  and EF-TRaman spectrum showed that the D-band/G-band ratio was approximately 1.305 and this result showed that defects have been generated from pristine MWCNT which D-band/G-band ratio is 1.087 .The effects of raw and functionalized MWCNTs concentrations, incubation time, and their interactions on bacterial richness and diversity were evaluated using multiple regression analyses. The results showed that the concentration of both fMWCNTs and raw MWCNTs did not show any correlation with OTUs richness and Chao index (All P > 0.05). In contrast, time was significantly correlated with OTUs richness and diversity for the two MWCNTs forms (All P < 0.05). Considering time and MWCNTs concentration together, there was an important correlation for OTUs richness and diversity indices (All P < 0.05), but only for functionalized carbon nanotubes (fMWCNTs) .OTU community composition did however differ between different concentrations of fMWCNTs,  but not with different concentrations of raw MWCNTs for Bray-Curtis dissimilarities. NMDS plots showed a clustering of soil samples according to MWCNT concentrations; nevertheless samples from soil with highest concentration of fMWCNTs showed a greater dissimilarity in their bacterial community composition compared to soil treated with raw MWCNTs .Considering the variation in the bacterial community over time, the NMDS plot showed a clustering of the soils sampled at different sampling times according to different MWCNT concentrations used in this experiment for fMWCNTs, but not for raw MWCNTs . An ANOSProteobacteria with 29% of the sequences, followed by Acidobacteria (20%), Actinobacteria (15%), Chloroflexi (9%), and Bacteroidetes (7%); around 4% of the sequences were unclassified.Overall, the most abundant bacterial phyla were Proteobacteria, Actinobacteria, Chloroflexi, and Bacteriodetes  represented by 5.6% of the total reads. This genus significantly decreased in abundance in the highest treatments with fMWCNTs at 2 weeks, but later in the experiment its abundance increased by the final time of sampling at 8 weeks. However, raw MWCNTs did not have any detectable effect on OTU relative abundances. Overall, even fMWCNTs did not have profound effects on the soil bacterial community, even though effects were detectable. Shifts in bacterial abundance were observed only for fMWCNTs with the greatest changes observed at highest concentrations (5000 μg/g).Changes in the relative abundance of the predominant bacterial genera in response to exposure to fMWCNTs and raw MWCNTs are illustrated in 2 > 94 in all cases). The bacterial abundance, as determined using qPCR, did not show any correlation with fMWCNTs or raw MWCNTs across different concentrations, except with fMWCNTs at zero time where P < 0.005 and R2 = 0.54 . High concentrations of both forms of MWCNTs increased the organic matter content of the soil.The ANOVA test results showed that the content of organic matter measured in the soil among different treatments with MWCNTs were highly significant  at the highest concentration of fMWCNTs then increased over time (8 weeks), whereas Actinobacteria increased at highest concentration of fMWCNTs, then later decreased. These findings suggest that the exposure of soil to fMWCNTs could in fact have some impact on carbon cycling by altering the microbial community [Actinobacteria (which undergo significant shifts in abundance) are important in the biogeochemical cycle of carbon in soils [Acidobacteria are ubiquitous and among the most abundant bacterial phyla in soil [Chloroflexi are commonly found in soils, also playing an important role in the biogeochemical cycle of carbon and the CO2 dynamics in soils [The relative abundance of the most common bacterial phyla was affected by the presence of fMWCNTs and showed differing responses to exposure to fMWCNTs. The abundance of ommunity . For exain soils ,54. In pin soils ,56. Acid in soil : their r in soil . The Chlin soils ,56,59. Sin soils –62.60 fullerene by Chung et al. [Despite the evident effects of exposure to fMWCNTs, overall it appears from our experiment that the soil bacterial community is quite resilient to the environmental perturbation caused by high concentrations of fMWCNTs. The community largely recovers from exposure to fMWCNTs by 8 weeks. It also appears that the soil bacterial community is resistant to perturbation from raw MWCNTs, with almost no observed effects on bacterial community. The observed lack of response to raw MWCNTs generally matches previous findings for untreated nanotubes and other carbon-based new materials ,64. For g et al.  and Tongg et al.  demonstrHowever, some studies have shown toxin-like effects of raw MWCNTs on bacteria. Rodrigues et al.  found thfMWCNTs are acidic in nature: pure fMWCNTs, after thorough washing, have a pH around 3 due to carboxyl groups that cover their surface. Our measurements of soil pH showed that pH was around 4 just after adding fMWCNTs to soil at 0 weeks for the highest fMWCNTs concentration, two units lower than the control without nanotubes, around 4.8 at 2 weeks, and around 5.5 at 8 weeks. There is abundant evidence that pH is crucial to bacterial community structure –69; in fThe overall picture is of rather weak—but still detectable—effects from fMWCNTs on soil bacterial community structure, combined with the lack of any observable effects from raw MWCNTs. This gives a generally reassuring picture in terms of the effects of MWCNTs on the soil environment. Even at the high concentrations used here, fMWCNTs apparently do not have profound effects on soil bacterial communities. The observed effects of fMWCNTs would, however, warrant further experimental investigations for any changes in soil nutrient cycling processes, using functional metagenomics or observations of fluxes.S1 Table(XLSX)Click here for additional data file.


Odocoileus hemionus). All body condition related metrics were measured on 2 neighboring study areas — a reference area that had received no habitat treatments and a treatment study area that had received mechanical removal of pinyon pine (Pinyus edulis) - Utah juniper (Juniperus osteosperma) forest, chemical control of weeds, and reseeding with preferred mule deer browse species. A consistent trend of higher %IFBF was observed in the treatment study area The relationships between habitat, body condition, life history characteristics, and fitness components of ungulates are interwoven and of interest to researchers as they strive to understand the impacts of a changing environment. With the increased availability of portable ultrasound machines and the refinement of hormonal assays, assessment of ungulate body condition has become an accessible monitoring strategy. We employed body condition scoring, estimation of % ingesta-free body fat (%IFBF), assessment of free thyroid hormones (FT4 and FT3), and assessment of pregnancy, as metrics to determine if landscape-level habitat treatments affected body condition of adult (≥1.5 years old) female mule deer ( Natural succession, climate mediated habitat change, deliberate habitat improvement, and direct habitat loss result in changing environments for wildlife populations. Due to the economic and social value of large ungulates, and in turn the datasets that management of these species foster, large ungulate populations are attractive to researchers hoping to elucidate the impacts of environmental change. Yet while wildlife professionals hasten to document the impacts of environmental change, the best barometer for measuring impacts to individuals and populations remains elusive. In general, the cascading effect of habitat quantity and quality on wildlife fitness has received attention for several decades The need to evaluate individual-level metrics as a response to environmental change rests on the assumption that the effects of environmental change may be subtle. These subtle effects may have long-term fitness consequences that remain undetected at short time intervals when assessed with population level monitoring strategies. The increased availability of portable ultrasound machines, coupled with the development and validation of robust body condition estimation models Total body fat and thyroid hormones can be viewed as metrics for the same general trait, overall deer health; however, they are parameters for different processes. Total body fat estimates, generated by merging ultrasonic rump fat measurements with body condition scoring ad libitum levels used by Bishop et al. was not a realistic expectation for our habitat management techniques As managers implement habitat management actions, or as they consider alternative large scale changes to habitat , they often wish to know if ungulate populations have been affected. Experimental research has demonstrated a strong connection between maternal body condition , pregnancy rates, as well as neonate and juvenile survival, when food was supplemented We conducted this research on 2 study areas near the southeastern tip of the Uncompahgre Plateau, near the city of Montrose in southwest Colorado , cliffrose (Purshia Mexicana), antelope bitterbrush (Purshia tridentate), mountain mahogany (Cercocarpus spp.), or rabbitbrush (Ericameria spp.) plants. Grasses included western wheatgrass (Pascopyrum smithii), green needlegrass (Nassella viridula), Indian ricegrass (Achnatherum hymenoides) and bluegrass (Poa spp.).The study areas were located in close proximity to one another to minimize spatial variation with Buckhorn being approximately 8.5 km north of BCSWA. Each study area was located on pinyon pine - Utah juniper forest winter range. These forests were late-seral stage, typified by open understory with occasional sagebrush  Data Analysis Unit (DAU) 40. This 2,437 kmDue to the proximity of the study areas, and to the overall topography, a high degree of spatial overlap on summer range occurred among deer that used these 2 distinct winter range segments . Due to this mixing on summer range, we assumed that body condition was equalized among deer prior to their arrival on our winter range study areas.Amelanchier alnifolia), and four-wing saltbush (Atriplex canescens). Weed control, via herbicide application, targeted cheatgrass (Bromus tectorum) and jointed goatgrass . The second stage of habitat treatments occurred on 78.34 ha (∼57%) of the original treatments. The delay between the first stage of habitat treatments and the initiation of mule deer body condition monitoring was a deliberate decision to accommodate temporal variation in vegetation response, post-treatment For our research, habitat treatments occurred on BCSWA in 2 stages. The first stage occurred in 1998, during which 135.98 ha (∼5%) of the 2,688 ha study area was exposed to mechanical roller-chopper treatments see . Roller-During early March of each winter (2007–2009), 30 adult female deer were captured via helicopter net-gunning Body condition scores were combined with ultrasound measurements to generate a scaled estimate of the total percent of the body that was ingesta-free body fat (%IFBF) for each animal cwww.r-project.org, accessed 23 May 2014). While individual mass was collected for animals at the time of capture, these data were not directly used in the estimation process for %IFBF. For each of the 3 response variables, a total of 64 models were compared. These 64 models comprised a balanced model set in which all response variables were included in an equal number of models. Models containing multiplicative interactions were not included in these model sets. This modeling approach facilitated the computation and comparison of cumulative model weights for each predictor variable and response variable combination 2+0.1474×FT4+0.1426×chestgirth, R2 = 0.609). Following those methods Prior to building body condition models, we tested for correlation between response variables. Based on the results of correlation analyses, we modeled 3 of the 5 body condition measurements  as a response to group covariates (study area and year) and to individual covariates . For all analyses, model selection and evaluation was based on AICEstimated %IFBF was more correlated with T4 (0.25) and FT4 (0.18) than with T3 (0.07) and FT3 (0.09). However, the highest overall correlations were observed within categories of thyroid hormones. T4 and FT4 had the highest correlation (0.89), whereas the correlation between T3 and FT3 was slightly lower (0.70). Correlation of concentrations between the 2 T4 hormones and the 2 T3 hormones were consistently between 0.40–0.45. Correlations among predictor variables were low with the highest observed correlation occurring between individual chest girth and individual hind foot length (0.31).The pooled, mean estimate of %IFBF for deer during this study was 7.17% (SD = 1.79). The observed mean value for BCSWA  accounted for less than 0.50 and contributed little to overall model predictions , Buckhorn  = 0.862 (SD = 0.345)). When pooled across study areas, observed mean pregnancy was lower in 2008 than in 2007 and 2009 (2007: 0.896 (SD = 0.307), 2008: 0.833 (SD = 0.376), 2009: 0.883 (SD = 0.324)). Probability of being pregnant was best predicted by the model Based on AICnescence . Explora2+0.000007×TT43. However, the predictive ability of our model was quite low (R2 = 0.106). When the model from similar research 2−0.050×FT4+0.058×chestgirth, R2 = 0.120), the model only received 2.6% of the model weight and had low predictive ability.Results of our exploratory analysis in which %IFBF was modeled using thyroid hormones were not congruent with results from earlier research The patterns reflected by our data tend to support our hypothesis that late winter body condition of adult female mule deer was elevated in our treatment study area as compared to our reference area. Both total fat reserves (%IFBF) and the metabolic capacity to utilize those reserves (FT4) appeared to be higher in treatment deer than in reference deer. However, the considerable variation that occurred within those estimates tempers this conclusion.c weight.For both %IFBF and FT4 results, study area and year were consistently among the most important covariates. In the case of FT4, these covariates accounted for >99% of the cumulative model weight see , demonstWe suspect that had we been able to increase the positive effects of habitat treatments, the importance of yearly variation may have been diminished. However, the treatments delivered as part of our research reflect those commonly utilized by land management agencies. We also note that >90% of the variation within our %IFBF data remained unexplained. Much of this variation was likely due to individual characteristics . Our study did not evaluate these important sources of variation. Thus, we conclude that while the effect of habitat management techniques are positive, thereby elevating the late winter body condition of mule deer, the magnitude of those effects are subtle and not be strong enough to eliminate the roles of yearly or individual variation. While the variation surrounding our estimates limited our ability to make a robust conclusion, this variation also serves as a road map for future research. Specifically, exploration of the components of this variation is warranted. Spatial and temporal aspects of this variation, largely regulated by annual moisture and weather patterns, need to be better understood. We echo the sentiments of others Despite design limitation, one of our key objectives was to evaluate the utility of body condition metrics in the context of actual habitat treatments, as opposed to artificial feeding utilized by other studies Population-level impacts stemming from the differences in body condition on our study areas were likely nominal. For example, we did not detect a meaningful difference in pregnancy rates between study areas. Likewise, while our study did not assess neonatal rates we do not think the number of fetuses produced per adult female in the treated area was greater than that in the reference area. However, we note that we did not actively seek low quality habitat to serve as our reference area. Rather, the reference area was defined by pinyon-juniper winter range that had not received vegetation treatments. This allowed us to test the hypothesis that habitat manipulation and improvement could be used to improve winter range in terms of late winter body condition. The magnitude of improvement in body condition could be expected to be amplified, relative to pre-treatment levels, if habitat treatments were targeted to poor quality habitat.In parallel research Appendix S1Data used in our analyses are available in (PDF)Click here for additional data file.