The purpose of this study was to investigate the indications for and approach to hysterectomy at Kingston General Hospital (KGH), a teaching hospital affiliated with Queen's University at Kingston, Ontario. In particular, in light of current literature and government standards suggesting the superiority of vaginal versus abdominal approaches and a high number of concurrent oophorectomies, the aim was to examine the circumstances in which concurrent oophorectomies were performed and to compare abdominal and vaginal hysterectomy outcomes.A retrospective chart audit of 372 consecutive hysterectomies performed in 2001 was completed. Data regarding patient characteristics, process of care and outcomes were collected. Data were analyzed using descriptive statistics, t-tests and linear and logistic regression.Average age was 48.5 years, mean body mass index (BMI) was 28.6, the mean length of stay (LOS) was 5.2 days using an abdominal approach and 3.0 days using a vaginal approach without laparoscopy. 14% of hysterectomies were performed vaginally, 5.9% were laparoscopically assisted vaginal hysterectomies and the rest were abdominal hysterectomies. The most common indication was dysfunctional or abnormal uterine bleeding (37%). The average age of those that had an oophorectomy  was 50.8 years versus 44.3 years for those that did not (p < .05). Factors associated with LOS included surgical approach, age and the number of concurrent procedures.A significant reduction in LOS was found using the vaginal approach. Both the patient and the health care system may benefit from the tendency towards an increased use of vaginal hysterectomies. The audit process demonstrated the usefulness of an on-going review mechanism to examine trends associated with common surgical procedures. In Canada in 2001, 446 hysterectomies were performed per 100 000 women .In response to the consistent demand for this procedure, recent reports have identified hysterectomy as a key health care indicator used to measure and compare hospital performance. In particular, the Ontario Hospital Association has identified the ratio of vaginal (VH) to abdominal hysterectomy (AH) as a measure of hospital performance , with a Considerable attention has also been directed towards the high rate of concurrent oophorectomy  with this procedure. This rate is of particular concern in premenopausal women because of the early menopause that ensues.The purpose of this study was to compare abdominal and vaginal approaches to hysterectomy, investigate the rate of concurrent oophorectomy, and identify factors associated with length of surgery, LOS and approach, by auditing all hysterectomies performed over a one-year period at a university teaching hospital.The study involved all patients who underwent a hysterectomy in 2001 at Kingston General Hospital (KGH), a teaching hospital affiliated with Queen's University at Kingston, Ontario. The Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board approved the study (OBGY-117-03). There were no exclusion criteria. Patients were identified by medical record tracking using ICD-9 codes and charts were reviewed to collect patient characteristics, length of stay, length of surgery, indication for surgery and approach. Readmissions, complications, infections and repeat laparotomies were also assessed.Menopause was defined as one year since the last menstrual period. Up to three indications for surgery were obtained from the chart, including those identified in clinic letters, admission sheets and operative reports. All indications were collected regardless of whether or not the post-operative diagnosis coincided with the preoperative diagnosis.VH included laparoscopically assisted vaginal hysterectomy (LAVH) and AH included VH converted to AH unless otherwise noted. Readmission was defined as a visit to the emergency room or an admission to the same hospital with a diagnosis that was related (readmission to another facility was unlikely as KGH is the only tertiary care facility in the region). Post-operative infections were defined as those that occurred within 30 days of surgery. A complication of excessive bleeding was defined as an intra-operative hemorrhage requiring transfusion or laparotomy, post-operative hematoma/seroma formation, or a significant post-operative vaginal bleed that required medical attention. All complications that occurred during the surgery or within 30 days of surgery were recorded, other than problems associated with removal of catheter, urinary retention, hypertension, hypotension, pain control, nausea and vomiting or headache. Any repeat laparotomy or unplanned laparotomy (other than for conversion of VH to AH) that occurred during the surgery or within 30 days of discharge was also noted.Follow up information was tracked using hospital chart and clinic note information from the six-week post-operative visit. All data were analyzed using SPSS statistical software (Version 11.0.1, SPSS Incorporated, Chicago, Illinois, 2002). Between-group comparisons utilized two-sample t-tests and one-way analysis of variance (continuous data) and Chi-square analyses . Predictors of LOS and length of surgery were identified using linear regression, while predictors of surgical approach were identified using logistic regression. Variables were offered into the models on the basis of the strength of the bivariate associations with the outcomes (p < 0.20).Three hundred and seventy two women underwent a hysterectomy in 2001. The characteristics of these patients can be found in Table The majority of hysterectomies were AH (78%), 14% were VH, 5.9% were LAVH and 2.2% were VH converted to AH. Total hysterectomies accounted for 79.8% of hysterectomies, 16.1% were subtotal, and 4% were radical or modified radical hysterectomies. There were no significant differences between patients who had a subtotal and those that had a total hysterectomy for BMI, age, LOS, length of surgery, number of infections, or number of complications. The patients differed only in terms of parity, in that those who underwent a total hysterectomy had more children (2.12 versus 1.66, p = 0.026).A concurrent procedure was performed in 26.6% of patients. This included biopsies (10.5%), reparative surgery (5.9%), procedures to establish urinary continence (3.5%), appendectomies (1.9%), and surgery to manage intra-operative events (2.2%). Table Fifty-eight (15.6%) of the patients had a diagnosis of cancer pre-operatively, which rose to 76 (20.4%) post-operatively. The population with cancer was older, had higher BMIs, longer surgeries, and longer lengths of stay than those without cancer Table .Twenty-six patients visited the emergency room within 30 days of their discharge and an additional nineteen patients were readmitted to the hospital. Table Infections occurred in 15.3% of patients, including urinary tract infections (7.5%), incision site infections (5.6%) and pelvic infections (2.2%). Those who developed an infection had a higher mean BMI (p = 0.018), longer LOS (p = 0.018) and longer length of surgery (p = 0.036) than those who did not.Four percent of patients had a repeat laparotomy or unplanned laparotomy (not including those for conversion of VH to AH). Other complications occurred in 24.5% of patients, the most common being excessive bleeding (11.3%) and post-operative ileus (5.4%). Other complications involving the bladder, bowel, pulmonary function, cardiac function or drug reactions occurred in less than 2% of patients respectively.Table A comparison of the abdominal and vaginal approaches revealed no differences in terms of incidence of infection, readmission to the ER or hospital, incidence of excessive bleeding or complication rate.LAVH and VH converted to AH were excluded from all regression analyses as they represented subgroups that were clinically different than routine AH and VH. Table Logistic regression for approach of hysterectomy indicated that a patient was 1.1 times more likely to have an AH for each one-point increase in BMI (p = 0.003), 47.6 times more likely to have an AH if she had a concurrent unilateral or bilateral oophorectomy (p < 0.001) and 1.7 times more likely to have a VH with each additional child (p < 0.001).The majority of the patients were overweight (29.6%, BMI 25–29.9) or obese (36.6%, BMI ≥ 30). These numbers define a population whose obesity level is 21.8 percentage points above the national average and although there is no known average BMI for all hysterectomy patients in Canada for comparison, the high obesity rate at this centre may have contributed to the reliance on the abdominal approach. A patient was in fact eleven times more likely to have an AH for every 10-point increase in BMI. Although recent studies exclude BMI as a factor in determining the route of hysterectomy, it has been noted that obesity of the buttocks may interfere with the exposure necessary for a VH [The general trend in determining the route of hysterectomy has been to challenge the validity of the exclusionary criteria for VH, such as nulliparity, larger uterine size, previous cesarean delivery, and pelvic laparotomy. These are no longer considered to be strong contraindications to a vaginal approach -11. Yet The overall ratio of abdominal to vaginal  surgeries is 5.6:1 but when only considering those surgeries performed for indications other than cancer (cancer found pre or post operatively), the ratio reduces to 3.9:1. This is consistent with the fact that most malignant indications for surgery require an abdominal approach in order to ensure access to structures and to allow for staging procedures. Our data did not demonstrate a significant difference between AH and VH in terms of outcome variables such as the rate of infection or complication, however, the two day reduction in LOS for VH may have significant cost reduction potential ,13. In oThe merit of performing a concurrent oophorectomy during hysterectomy continues to be debated for women not at high risk of developing ovarian cancer. Estimates regarding the number of prophylactic oophorectomies needed to prevent one case of ovarian cancer range from 200  to 300 . BenefitThe limitations of this study include uneven distribution of patients in each treatment group and lack of randomization due to the nature of the retrospective chart review process. Furthermore, because the audit process relied entirely on chart documentation, information may have been missed or incorrect as a result of improper or absent documentation. The broad range of information collected also prevented the researchers from employing more rigorous definitions and verification of outcomes. The retrospective nature of the study precluded an evaluation of the decision making process leading to oophorectomy as well as the influence of pre-operative indications, uterine size, parity, previous c-section and concurrent oophorectomy on surgical approach. This would need to be addressed prospectively, by surveying the surgeons at the time that the decision was made.Both the patient and the health care system may benefit from the trend towards increased use of vaginal hysterectomies. However, the abdominal approach continues to dominate, likely related to patient size, surgeon preference and the need for adnexal surgery. The audit process proved to be an important method by which to assess trends associated with common surgical procedures. This study raises important questions about the relationship between patient characteristics, surgical approach and the indications for surgery, and a prospective approach, designed to address these questions more fully, is now indicated. Furthermore, in light of recent evidence  demonstrThe author(s) declare that they have no competing interests.AT performed data collection, participated in the study design and coordination and participated in drafting the manuscript. WH performed the statistical analysis and participated in drafting the manuscript. RHG conceived the study and participated in its design and coordination and participated in drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Trypanosoma evansi (T. evansi) RoTat 1.2 Variable Surface Glycoprotein (VSG), a primer pair was designed targeting the DNA region lacking homology to other known VSG genes. A total of 39 different trypanosome stocks were tested using the RoTat 1.2 based Polymerase Chain Reaction (PCR).Based on the recently sequenced gene coding for the T. evansi and in seven out of nine T. equiperdum strains tested. This product was not detected in the DNA from T. b. brucei, T. b. gambiense, T. b. rhodesiense, T. congolense, T. vivax and T. theileri parasites. The Rotat 1.2 PCR detects as few as 10 trypanosomes per reaction with purified DNA from blood samples, i.e. 50 trypanosomes/ml.This PCR yielded a 205 bp product in all T. evansi strains, except T. evansi type B, and is especially useful in dyskinetoplastic strains where kDNA based markers may fail to amplify. Furthermore, our data support previous suggestions that some T. evansi stocks have been previously misclassified as T. equiperdum.PCR amplification of the RoTat 1.2 VSG gene is a specific marker for  Trypanosoma evansi. T. evansi belongs to the subgenus Trypanozoon, together with T. equiperdum and T. brucei. The parasite can infect different host species and is mechanically transmitted by different biting flies such as Tabanidae and Stomoxys as well as by vampire bats such as Desmodus rotondus [T. evansi infections of cattle and buffaloes usually lead to a pronounced immunosuppression resulting in an increased susceptibility to other opportunistic diseases such as Pasteurella and anthrax [Surra is an animal disease occurring in Africa, Asia and Latin America, caused by rotondus . Camels  anthrax .T. evansi infection usually starts with clinical symptoms or the detection of antibodies to T. evansi. Conclusive evidence of T. evansi infection, however, relies on detection of the parasite in the blood or tissue fluids of infected animals. Unfortunately, parasitological techniques cannot always detect ongoing infections as the level of parasitaemia is often low and fluctuating, particularly during the chronic stage of the disease [Diagnosis of a  disease .Trypanozoon specific primers have been designed previously: TBR primers which target a 177 bp repeat [T. congolense and T. vivax infections exist as well [Trypanozoon subgenus still remains a challenging issue. For T. evansi infections, the only specific test available so far is based on the detection of a kinetoplast DNA sequence [T. evansi RoTat 5.1 [T. evansi parasites. Recently, Ventura et al. [T. evansi based on a Random Amplified Polymorphic DNA (RAPD) fragment. The taxon specificity of this PCR remains uncertain since it was only tested on nine T. evansi strains, one T. equiperdum, two T. b. gambiense and one T. b. rhodesiense. Following evidence that the variable epitope of RoTat 1.2 VSG is expressed by all T. evansi strains tested so far [T. evansi but not in T. brucei isolates [As an alternative to parasitological tests, DNA detection based on PCR has been proposed. p repeat , pMUTEC p repeat  and ORPHp repeat . Most ofp repeat , water bp repeat  or goatsp repeat . PCR tes as well . The devsequence ,13. HoweoTat 5.1  and E152oTat 5.1  casts dod so far , and thaT. evansi populations (lanes 3–8). Moreover, the same fragment was found in seven out of the nine T. equiperdum populations tested. The T. equiperdum BoTat 1.1 was PCR negative (lane 10), while the T. equiperdum OVI strain yielded a PCR product shorter than 205 bp (lane 11) probably due to mispriming. All other tested trypanosome populations, including six T. b. brucei, eight T. b. gambiense, five T. b. rhodesiense, two T. congolense, one T. vivax and one T. theileri, were negative. (lanes 18–40). As a negative control, a PCR-mix without template DNA was included (lane 2). Sequencing of the positive samples revealed that all amplicon were identical (data not shown). The weak band in OVI did not yield sufficient material to enable sequencing.The 39 different trypanosome stocks used in this study are listed in Table 1 see . They we5 trypanosomes down to 1 trypanosome per 200 μl sample) of RoTat 1.2 trypanosomes in mouse blood was prepared to determine the analytical sensitivity of the PCR. As shown in figure A tenfold dilution series (10T. evansi strains and in seven out of nine T. equiperdum. As with the RoTat 1.2 PCR only T. equiperdum strains OVI and BoTat 1.1 remained negative. Unexpectedly, four out of six T. b. brucei (AnTat 2.2, AnTat 5.2, TSW 196 and KETRI 2494) and two T. b. gambiense type II strains (ABBA and LIGO) tested positive in this PCR (data not shown).To evaluate the RoTat 1.2 diagnostic system alongside other published methods, we compared our method to the PCR-Te664 method as published by Ventura et al.  using thT. evansi from the other members of the Trypanozoon subgenus. The study is an extension of the initial observation that the RoTat 1.2 VSG gene only is found in T. evansi and not in T. brucei strains [T. evansi rather than the use of this VSG in diagnosis of Salivarian trypanosomes.This study was initiated to develop a specific PCR test that would be able to distinguish  strains . This stT.b. gambiense infections (sleeping sickness). In these studies, five different primers derived from VSG genes, AnTat 11.17, LiTat 1.3, 117, 2 K and U2 were used in PCR screening of different trypanosome populations, originating from distinct geographical locations [T.b. gambiense from T.b. brucei parasites from most foci of sleeping sickness in countries such as Nigeria, Cameroon, Côte d'Ivoire, R. P. Congo/Brazza. and Sudan. However, populations originating from the Moyo focus in North-west Uganda and from Cameroon were shown to be negative in AnTat 11.17 and in LiTat 1.3 (2 K) PCRs respectively. According to Bromidge et al. [T. brucei populations tested. In T. evansi, a similar phenomenon may occur in certain Kenyan isolates. A recent study by Ngaira et al. [T. evansi stocks in the Isiolo district in Kenya seem to lack the Rotat 1.2 VSG gene. It is believed that these stabilates belong to the T. evansi type B group. So far, this type of T. evansi has only been observed in this specific region in Kenya [T. evansi isolated elsewhere, are from the classical T. evansi type A group. Thus, we assume that, except for these few Kenyan strains belonging to the type B group, our PCR is specific for T. evansi.Previously, other research groups have used VSG genes as target sequences for PCR detection of ocations -20. AnTae et al. , this mia et al.  pointed in Kenya ,23. To oet al. [T. b. brucei, nor with T. b. gambiense type II was observed. However, regarding T. equiperdum, both PCR test positive for the same seven T. equiperdum strains and are both negative for the BoTat 1.1 and OVI strains. Since the RAPD fragment (AF397194) shares no homology with the Rotat 1.2 VSG gene (AF317914) and is not found within the expression site of trypanosomes, both sequences can be considered as independent molecular markers. Based on the observations with both markers, it appears that on the genomic level the Botat 1.1 and the OVI strains are different from the other T. equiperdum and T. evansi strains. The observed analytical sensitivity with the RoTat 1.2 PCR is comparable to what was reported for the Te664 PCR (25 cells per reaction) [Compared to the PCR-Te664 presented by Ventura et al. , the PCReaction) .T. equiperdum strains corresponds with the serological evidence that rabbits experimentally infected with these strains develop RoTat 1.2 specific lytic antibodies within 30 days post infection [T. evansi specific and that RoTat 1.2 PCR positive T. equiperdum strains are actually T. evansi and not T. equiperdum. Indeed, in a previous molecular characterization study using Random Amplified Polymorphic DNA (RAPD) and the Multiplex-endonuclease Genotyping Approach (MEGA) it appeared that the T. equiperdum collection is not as homogenous as previously believed and that the generally followed concept that T. equiperdum is very closely related to T. evansi and more distant from T. b. brucei, seems incorrect. From the cluster analysis on the available strains, it appeared that only two clusters can be identified: a homogeneous T. evansi/T. equiperdum cluster and a more heterogeneous T. b. brucei/T. equiperdum cluster [T. evansi/T. equiperdum cluster are all PCR RoTat 1.2 VSG positive while the strains found in the more heterogeneous T. b. brucei/T. equiperdum cluster, in casu BoTat 1.1 and OVI are PCR RoTat 1.2 VSG negative.The presence of a RoTat 1.2 specific DNA sequence in some nfection . In cont cluster . InteresT. evansi strains, except T. evansi type B, and is especially useful in dyskinetoplastic strains where kDNA based markers may fail to amplify. Furthermore, our data support previous suggestions that some T. evansi stocks have been previously misclassified as T. equiperdum.PCR amplification of the RoTat 1.2 VSG gene is a specific marker for T. equiperdum strains, BoTat 1.1, OVI and STIB 818 are well documented, i.e. known origin and host. The other six are putative T. equiperdum, based on publications or on their use as reference strains in different national dourine reference laboratories [A total of 39 different trypanosome populations were used in this study. They belong to 39 stocks and six species, isolated from a variety of host species at distinct geographical locations (Table 1 see ). Only tratories -30.in vitro in Cunningham's medium [2HPO4.2H20, 2 mM NaHPO4, 80 mM glucose, 100 mM sacharose, pH 8.0). Bloodstream form trypanosomes were expanded in mice and rats and were purified from the blood by di-ethyl-amino-ethyl (DEAE) chromatography [2HPO4.2H20, 2 mM NaHPO4, 80 mM glucose, 29 mM NaCl, pH 8.0). Trypanosome sediments were subsequently stored at -80°C.Procyclic trypanosome populations were grown s medium  and in ts medium . Pure prtography , followe7 cells) were resuspended in 200 μl of Phosphate Buffered Saline (PBS) (8.1 mM Na2HPO4.2H20, 1.4 mM NaHPO4, 140 mM NaCl, pH 7.4) and the trypanosome DNA was extracted using the commercially available QIAamp DNA mini kit (Westburg, Leusden, The Netherlands), resulting in pure DNA in 200 μl of TE buffer. The typical yield of DNA extracted from a 20 μl pellet was 150 ng/μl or 30 μg total DNA. The extracts obtained were diluted 200 times in water and divided into aliquots of 2 ml in microcentrifuge tubes for storage at -20°C.Twenty μl of trypanosome sediment  resulting in 200 μl of extracted DNA in Millipore water. Manipulation was performed according to the manufacturer's instructions.et al. [ann. 59°C and RoTat 1.2 Reverse ATT AGT GCT GCG TGT GTT CG, Tann. 59°C.Primers were derived from the RoTat 1.2 VSG sequence AF317914), recently cloned and sequenced by Urakawa 914, rece2 (Promega, UK), 200 μM of each of the four dNTPs (Roche, Mannheim, Germany) and 0.8 μM of each primer (Gibco BRL, UK).Twenty μl of extracted DNA were mixed with 30 μl of a PCR-mix containing: 1 U Taq DNA recombinant polymerase (Promega, UK), PCR buffer (Promega, UK), 2.5 mM MgCl® Trio-block thermocycler. Cycling conditions were as follows: denaturation for 4 min. at 94°C, followed by 40 amplification cycles of 1 min. denaturation at 94°C, 1 min. primer-template annealing at 59°C and 1 min. polymerization at 72°C. A final elongation step was carried out for 5 min. at 72°C.All amplifications were carried out in a BiometraTwenty μl of the PCR product and ten μl of a 100 bp size marker (MBI Fermentas, Germany) were subjected to electrophoresis in a 2 % agarose gel (25 min. at 100 V). Gels were stained with ethidium bromide (0.5 μg/ml) (Sigma, USA) and analyzed on an Imagemaster Video Detection System (Pharmacia, UK).et al. [Taq DNA polymerase was purchased from another distributor, i.e. Promega (UK) instead of Gibco BRL (UK).PCR on purified DNA samples was performed using primers and PCR conditions according to Ventura et al. . Only thNone declared.FC carried out the molecular work and drafted the manuscript. MR and TU participated in the molecular analysis. PM, BG and PB participated in the design and co-ordination of the study. All authors read and approved the final manuscript.Trypanosoma (T.) populations used in this studyTable 1. Data on the different Click here for file


One problem in the mobilization of patients with neurological diseases, such as spinal cord injury, is the circulatory collapse that occurs while changing from supine to vertical position because of the missing venous pump due to paralyzed leg muscles. Therefore, a tilt table with integrated stepping device (tilt stepper) was developed, which allows passive stepping movements for performing locomotion training in an early state of rehabilitation. The aim of this pilot study was to investigate if passive stepping and cycling movements of the legs during tilt table training could stabilize blood circulation and prevent neurally-mediated syncope in healthy young adults.In the first experiment, healthy subjects were tested on a traditional tilt table. Subjects who had a syncope or near-syncope in this condition underwent a second trial on the tilt stepper. In the second experiment, a group of healthy subjects was investigated on a traditional tilt table, the second group on the tilt ergometer, a device that allows cycling movements during tilt table training. We used the chi-square test to compare the occurrence of near-syncope/syncope in both groups (tilt table/tilt stepper and tilt table/tilt ergometer) and ANOVA to compare the blood pressure and heart rate between the groups at the four time intervals (supine, at 2 minutes, at 6 minutes and end of head-up tilt).Separate chi-square tests performed for each experiment showed significant differences in the occurrence of near syncope or syncope based on the device used. Comparison of the two groups (tilt stepper/ tilt table) in experiment one (ANOVA) showed that blood pressure was significantly higher at the end of head-up tilt on the tilt stepper and on the tilt table there was a greater increase in heart rate (2 minutes after head-up tilt). Comparison of the two groups (tilt ergometer/tilt table) in experiment 2 (ANOVA) showed that blood pressure was significantly higher on the tilt ergometer at the end of head-up tilt and on the tilt table the increase in heart rate was significantly larger (at 6 min and end of head-up tilt).Stabilization of blood circulation and prevention of benign syncope can be achieved by passive leg movement during a tilt table test in healthy adults. Several studies have confirmed that lack of movement leads quickly to profound negative physiological and biochemical changes in all organs and systems of the body -5. It isHead-up tilt table testing has been used for over 50 years by physiologists and physicians for many purposes. This includes the study of the human body's heart rate and blood pressure adaptations to changes in position, for modeling responses to hemorrhage, as a technique for evaluating of orthostatic hypotension, as a method to study hemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction and hypertension, as well as a tool for drug research ,10-14. IIn addition to the traditional tilt table, a novel apparatus with stepping device (tilt stepper) was developed in 1998 at the research department of the Paraplegia Centre of the Balgrist University Hospital in Zurich, Switzerland in collaboration with the Department Orthopaedic II of the Orthopaedic Hospital of Heidelberg to enable a mobilization with stabilized circulation and to begin with a locomotion training in an early state of rehabilitation.In the tilt stepper, the patient is strapped by a safety belt to the tilt table while the legs are moved passively in a physiological stepping pattern Figure . The incThere are only a few studies that have investigated how passive movement of the legs during a tilt table treatment affects circulation. In these studies, either functional electrical stimulation of the leg muscles -21 was uThe aim of our experiments was to investigate if passive stepping and cycling movements of the legs during a tilt table test can stabilize blood circulation and prevent neurally mediated syncope in healthy young adults.With the permission from the local Ethics Committee and the informed consent of the volunteers, the response of the blood circulation was analyzed in healthy subjects. The exclusion criteria included: recurrent syncope or near-syncope in clinical history, regular medication, abuse of nicotine or alcohol, cardiovascular or neurological diseases, acute or chronic infections, psychiatric disorder and body mass index <18 or >25. All subjects underwent a physical investigation and an ECG was completed one week before the experiment.In the first experiment, we examined 12 healthy young adults (age 24 ± 5 years) on a traditional tilt table. The subjects, who had syncope or near-syncope were treated on the tilt stepper after a waiting period of 4 weeks. Syncope was defined as a transient loss of consciousness associated with a loss of postural tone. Near-syncope was defined as the appearance of pallor, nausea, light-headedness, diaphoresis or blurred vision. Both conditions were associated with the following hemodynamic changes: a decrease in systolic blood pressure > 60% from baseline values or an absolute value < 80 mmHg (vasodepressor response) and/or a decrease in heart rate > 30 % form the baseline value or an absolute value < 40 beats/min (cardio-inhibitory response) .In the second experiment, we enrolled 42 healthy subjects (age 27 ± 4 years). They were randomized into two groups: group I (23 subjects) was put on a traditional tilt table, while the Group II (19 subjects) on a tilt ergometer. The age of the subjects was restricted to below 35 years, because the cardiovascular response is strongly dependent on age .The aim of the first experiment was to investigate if the blood circulation could be stabilized in people who have a disposition for an "early" appearance of a neurally-mediated syncope on a traditional tilt table. The appearance of a neurally-mediated syncope is physiological and it may occur in all subjects. The interpersonal difference lies in the duration that the subject can be in standing posture until syncope or near-syncope occurs. A decrease of the systolic blood pressure up to maximal 15 mmHg and/or an increase in heart rate up to 20 bpm during the first 6 minutes are considered as a normal reaction to compensate the change in the position of the body .The blood pressure was non-invasively measured with a tonometric blood pressure device. Subjects who suffered a syncope or near-syncope during the first session on the traditional tilt table were in the second session treated on the tilt stepper. In the second experiment, we investigated the effect of passively induced movements on circulation by a cycle ergometer on a tilt table. We enrolled 42 subjects: 23 on a traditional tilt table and 19 on the tilt ergometer.In both experiments, after 15 minutes of rest the subjects were tilted head-upright at a 75° angle and were returned to the supine position if a syncope or near-syncope occurred or after completion at 30 minutes. Heart rate and blood pressure were measured continuously and non-invasively. Head-up tilt tests were performed in the morning in a dim room. All subjects were instructed to fast overnight and relax the muscles of their lower limbs during the trials. This was monitored with an EMG-measurement on legs , randomly tested in the first experiment and regularly tested during the second experiment. The EMG signals were amplified and transferred to a personal computer. They were recorded by a data acquisition tool (SolEasy by Aleasolution GmbH, Zurich, CH).The tilt stepper is a traditional tilt table (Gymna, Belgium) combined with an integrated leg drive that allows a passive movement of the lower extremities Figures  and 2The leg drive that is connected to the thigh by a cuff induces a hip flexion or extension movement. As the feet of the patient are fixed to footplates, the knee is also flexed or extended, respectively. In those phases where the hip and knee joints are extended, the leg pushes down a spring-dampened footplate, which is then again pushed against a foot spring that is mounted within these plates. This footplate generates a loading force on the foot sole of the patient during extension. Applying this cycle of flexion and extension in an alternating way leads to physiological kinetics of the generated motion. A special mechanism is mounted under the hip joint and allows for adjustment of hip extension up to 20°.Depending on the blood circulation condition of the patient, the device can be tilted to different angles up to a vertical position. This makes it possible for the patient to become accustomed, step-by-step, to the upright position in combination with passive leg movements. The speed of the alternating stepping movements and the range of motion of hip/knee joints can be adjusted by a control panel. The basic construction consists of a linear drive (Parker-Hannifin, Germany), with a precision ball screw that is driven by a synchronous motor via toothed belt (maximum speed 450 mm/sec, maximum force 1400 N, maximum torque of 400 Nm at the hip joint). The movement frequencies range from 0.2 to 0.5 Hz (i.e. one cycle of flexion and extension takes between 2 and 5 sec).To secure subjects on the tilt table during experiments, fixation with a special harness was used during all experiments Figure .The tilt ergometer consists of a traditional tilt table with an additional ergometer device (Tera Joy Germany) that allows a passive cycling movement of the lower extremities. From a technical point of view, the tilt ergometer construction is simpler than the tilt stepper, but it generates a non-physiological motion concerning gait phase related forces on the foot sole. The cycle frequency was between 0.2–0.5 Hz.Blood pressure was measured continuously and non-invasively by a Colin CBM-7000 (Hayashi, Komaki City, Japan). The Colin CBM – 7000 is a tonometric blood pressure device that allows measuring beat-to-beat blood pressure (systolic, mean, diastolic), continuous arterial blood pressure waveform, beat-to-beat and continuous electrocardiography.In both experiments we used the chi-square test to compare the occurrence of near-syncope/syncope in both groups (tilt table/tilt stepper and tilt table/tilt ergometer). We performed 2 by 4 repeated measures ANOVAs with 2 between factors (device group – namely tilt table vs. tilt stepper or tilt table vs. tilt ergometer), 4 within factors (time – supine, 2 minutes, 6 minutes and end of head-up tilt) and in their interaction (groups × time) for blood pressure and heart rate. Pairwise comparisons were made with the t-test with additional Bonferroni's correction.2 (1.1) = 6.465, p = 0.011). Table In the first experiment, 7 of 12 subjects (58%) had a syncope or near-syncope on the traditional tilt table. There was an obvious increase in heart rate in the first 6 minutes after changing the position from supine to upright. None of these 7 subjects had a syncope or near-syncope during the treatment session on the tilt stepper 4 weeks later. Comparing the occurrence of near syncope/syncope in both sessions with the chi-square test, there was a significant difference  = 4.66, p < 0.0743), but there were significant differences between groups  = 6.33, p < 0.0016)) and in the interactions (F(3,18) = 7.24, p < 0.0022). The blood pressure differs between the two treatments at the end of head – up tilt (p < 0.0029), but not at 2 minutes (p < 1.000) and at 6 minutes (p < 1.000) . However, there could be shown a trend for a higher blood pressure at 2 minutes and at 6 minutes after head-up tilt in the group treated in the tilt stepper.There were significant differences for heart rate within each group  = 12.17, p < 0.0130) between groups  = 21.16, p < 0.0001) and in the interactions (F (3, 18) = 8.68, p < 0.0009). For the group treated on the traditional tilt table, pairwise comparisons with the t-test with additional Bonferroni's correction showed a significantly higher heart rate at 2 minutes (p < 0.0.0060), but no significant differences at 6 minutes (p < 0.2051) and at the end of head-up tilt (p < 1.000).2 (1.1) = 5.443) there was a significant difference (p = 0.021) (Table In the second experiment, 13 of 23 subjects (57 %) who were on the traditional tilt table had syncope (3) or near-syncope (10). None of the 19 subjects who were on the tilt ergometer had syncope but 4 subjects had near-syncope (21%). Comparing the occurrence of near syncope/syncope in both sessions with the chi-square test  = 34.43, p < 0.0001) between groups  = 13.42, p < 0.0001)) and in the interactions (F(3,18) = 10.95, p < 0.0001). Pairwise comparisons with the t-test  showed no significant differences at 2 minutes (p < 0.5221) and at 6 minutes (p < 0.4429) but a significant difference at the end of head – up tilt (p < 0.0001). However, there could be shown a trend for a higher blood pressure at 2 minutes and at 6 minutes after head-up tilt in the group treated on the tilt ergometer. There were significant differences for heart rate within each group  = 12.17, p < 0.0130), between groups  = 21.16, p < 0.0001), and in the interactions (F(3,18) = 8.68, p < 0.0009). Pairwise comparisons with the t-test  showed no significant differences at 2 minutes (p < 0.3317), but a significantly higher heart rate in the group treated on the tilt table at 6 minutes (p < 0.0007) and at the end of head – up tilt (p < 0.0002).All subjects on the tilt stepper and tilt ergometer completed 30 minutes of head-up tilt. The duration of the head-up tilt was different in the group on the traditional tilt table, as an abrupt decrease of blood pressure or symptoms of near-syncope occurred.In the head-up tilt position the subject stands on the footplates on the tilt stepper, whereas in the tilt ergometer the harness holds the whole body weight. The subjects who were investigated on the tilt stepper felt comfortable during the whole experiment, whereas the subjects examined on the tilt ergometer in experiment two complained of discomfort. The subjects on the tilt ergometer experienced more discomfort because of the perception of no lower limb support. These statements were subjective; no standardized assessment instrument was used to measure the comfort.Tables In Figures Figure Figure The tilt table is an apparatus that has become an important part in the evaluation of patients with unexplained syncope or loss of consciousness ,24,33. IAlthough the tilt table has become an accepted diagnostic tool, there are no comparable studies with the tilt table in which the effect of passive leg motion on circulation have been investigated.The aim of these two experiments was to investigate if passive leg movements during head-up tilt can prevent syncope. The data in the present study show a stabilizing effect on the blood circulation and this study suggests that there is an effect on preventing neurally-mediated syncope by both devices. In the first experiment, none of the subjects who had syncope/near-syncope on the traditional tilt table had syncope/near-syncope four weeks later on the tilt stepper. In the second experiment, only 4 subjects who were treated on the tilt ergometer had near-syncope. In both experiments the increase of heart rate was larger in the group tested on the traditional tilt table. A correlation between heart rate and appearance of syncope was described ,36. An iIn the first experiment we treated the same subject twice on a tilt table. It cannot be excluded that an adaptation to the orthostatic change occurred in these subjects. However, there was an interval of four weeks between the first treatment on the traditional tilt table and the second treatment on the tilt stepper. Therefore, a training effect or an effect of habituation, such as described in another study in which patients suffering from syncope were treated each day over 6 weeks, seems to be unrealistic .The results in both experiments indicate that blood circulation can be stabilized by passive leg movements. However, the movements of the two devices used in these experiments are very different: on the tilt stepper there are stepping like movements and the legs can be loaded during extension and unloaded in flexion. In the tilt ergometer, the movements are the other way round. There might be more afferent input from the load receptors in the tilt stepper compared to the tilt ergometer. For example it could be shown that the load moments acting about the bilateral hip, knee and ankle joint axes during cycling are found to be generally lower than those induced during normal level walking  and concIn conclusion, we could show that both passive cycle and stepping movements of the legs during head-up tilt testing can stabilize blood circulation and prevent syncope in young healthy people. In further studies, we aim to investigate if the tilt stepper could become a helpful device for patients suffering from neurological diseases.


There is evidence that groups of people with schizophrenia have deficits in Theory of Mind (ToM) capabilities. Previous studies have found these to be linked to psychotic symptoms (or psychotic symptom severity) particularly the presence of delusions and hallucinations.A visual joke ToM paradigm was employed where subjects were asked to describe two types of cartoon images, those of a purely Physical nature and those requiring inferences of mental states for interpretation, and to grade them for humour and difficulty. Twenty individuals with a DSM-lV diagnosis of schizophrenia and 20 healthy matched controls were studied. Severity of current psychopathology was measured using the Krawiecka standardized scale of psychotic symptoms. IQ was estimated using the Ammons and Ammons quick test.Individuals with schizophrenia performed significantly worse than controls in both conditions, this difference being most marked in the ToM condition. No relationship was found for poor ToM performance and psychotic positive symptomatology, specifically delusions and hallucinations.There was evidence for a compromised ToM capability in the schizophrenia group on this visual joke task. In this instance this could not be linked to particular symptomatology. Theory of Mind (ToM) describes the ability to recognise that other people have minds containing beliefs and intentions and to be able to interpret these correctly. The term, first coined by Premack and Woodruff , is alsoToM ability has been conceived as a capacity to represent epistemic mental states comprising an agent and an attitude to the truth of a proposition e.g. "Peter believes that it is raining" ,5. The tIt is widely reported that there are observed ToM deficits in schizophrenia from the numerous behavioural and neuroimaging studies that have been conducted investigating this phenomenon [e.g. ]. It is Sarfati et al used a strictly pictorial task in which 3 picture cartoon sequences were shown depicting a character producing an action and the participants had to choose the fourth and final picture from a choice of three images . SuccessSarfati et al then enlarged this experimental protocol by introducing a verbal dimension to the task . There wLangdon et al, used a task comprised of 4 card black and white cartoon picture sequences of four varieties: social script stories testing logical reasoning about people without needing to infer mental states, mechanical stories testing Physical cause and effect reasoning, false belief stories testing general mind reading abilities and capture stories testing inhibitory control. Cards were place face down in a square layout and participants had to turn the cards over and place them in the correct order to show a logical sequence of events. In order to control for possible contributory effects of executive dysfunction, inhibitory control was tested using capture picture-sequences and executive planning was tested using the Tower of London task.In both studies, it was found that individuals with schizophrenia showed a selective ToM impairment which could not be completely explained by reasoning, planning deficits or poor inhibitory control ,19.Brüne showed individuals a muddled cartoon 4 picture sequence depicting a ToM scenario between characters . The parCorcoran et al used visual jokes to look at potential ToM deficits in schizophrenia . Two setThe primary interest of the current study was to examine the associations between specific schizophrenic symptoms and ToM capabilities using the cartoon method devised by Corcoran , but witForty participants aged from 19–65 years were recruited for this study. Twenty of these had a diagnosis of DSM IV schizophrenia . These wTo assess their present symptomatology, the schizophrenia patients were assessed on the Krawiecka Standardized Scale for Rating Chronic Psychotic Patients . SymptomAll participants in this study gave written, informed consent.Sixty-three single-image cartoon jokes, printed on A4 cards were generously provided by the authors of previous studies . Thirty-It was explained to the subjects that they would be shown cartoons intended to be funny. The two complete sets of cartoons were then shown to each subject in turn. The order in which they were presented was alternated so that half the participants viewed the ToM cartoons first, and half viewed the ToM cartoons second.The subjects were shown each joke one by one and instructed to indicate to the observer when they believed they had understood its meaning. This response time was then recorded to the nearest second using a stopwatch. The participants then gave a short explanation of their interpretation of the joke's meaning. Responses were scored 1 for a correct answer and 0 for an incorrect answer. For a theory of mind answer to be correct, appropriate mental state language had to be used. Furthermore, participants were asked to subjectively grade each cartoon image for humour and difficulty on a scale of 1–5, where 1 was not funny or very easy and 5 very funny or very difficult respectively.Simple Physical descriptions of the scenario were required for the Physical joke responses to be scored correct. An example of acceptable responses can be viewed in Table Tests were all performed in quiet, distraction-free rooms.Data analysis was performed using SPSS for Windows Version 11.0.General linear model repeated measures ANOVA was used to determine the significance of any difference in the Physical versus ToM scores seen between the groups. General linear model ANCOVA controlling for Physical joke score was used to investigate the selectivity of any group difference in ToM capabilities. Linear regression analysis was used to relate Physical and ToM scores to Krawiecka sub-totals for positive, negative and non specific symptoms, individual Krawiecka symptoms, medication dose and joke block presentation order. Independent two-tailed t-tests were used to compare the group score differences in the two conditions , the average subjective ratings for humour and difficulty assigned to the stimuli by the participants, and the average response times to get the jokes.Using general linear model, repeated measures ANOVA, highly significant main effects were found for repeated measure (i.e. joke type: F = 112.9, p < 0.0001) and group (F = 42.6, p < 0.0001) as well as a significant interaction of group by joke (F = 10.3, p = 0.003). Table Follow-up t-tests comparing individuals with schizophrenia to controls were highly significant for both the ToM condition (p < 0.0001) and the Physical condition (p < 0.001).Additionally, within both the patient and control groups, scores were significantly worse for ToM jokes than Physical jokes (p < 0.0001 for both groups). However, the significant interaction showed that the difference of 10.6 for the patient group was greater than that for the controls (5.6). Using the general linear model, ANCOVA, controlling for Physical joke score, a significant group difference on ToM joke scores was still evident, F = 19.5, p < 0.05.The two groups were well matched for age, IQ and sex, and any difference between them was shown to be insignificant by independent 2-tailed t-test (p > 0.1). It was unnecessary, therefore, to perform regression analyses to co-vary for these factors.It was found via independent T-test analysis that there was no significant difference between the schizophrenia patients and control participants' subjective ratings for humour and difficulty or between the average response times of correct responses p > 0.05). Results are summarized in Table . ResultsFurthermore, linear regression indicated that the order of presentation of the joke sets had no significant effect on ToM or Physical joke scores.Correlations were run to investigate the relationships between performances on ToM and Physical jokes and different symptom scores . These data are displayed in Table As stated, performance was not significantly reduced in association with increasing severity of positive or negative symptoms as a whole or delusions and hallucinations specifically.The features of depression, incoherence and poverty of speech were also analysed to see if they could be having an effect on the patients ToM and Physical joke performance but there were no significant findings.The converted equivalent daily chlorpromazine patient medication doses were correlated to performance and also found to be non significant for both cartoon conditions.This study showed that individuals with schizophrenia and normal IQ had a poorer understanding of both types of jokes (and at least a reduced ability to relay their humorous intent) than matched healthy controls. This is to be expected, as schizophrenia patients have previously been reported to show poor appreciation of humour . It seemHowever, the difference between the Physical and ToM joke scores was significantly greater for schizophrenia patients, than controls. This implies that it is some aspect of the schizophrenia disease process that is associated with ToM impairment in the patient group, rather than a general difficulty with appreciation of humour.If the schizophrenia group had a poorer understanding of the jokes then we would expect this to be reflected in the subjective gradings for humour and difficulty. As shown in table It was found that both groups found the ToM jokes significantly more difficult than the Physical ones. The former were certainly more detailed and by their very nature were comprised of characters in ToM scenarios. It could be that these jokes were more difficult to understand, but there was no significant difference between the response times of the two joke types for either group. Poor verbal report of mentalistic terms may be an intrinsic feature of schizophrenia and this could have resulted in this schizophrenia group's poor performance on this set of jokes.Language and thought are intrinsically linked and the question arises as to whether disordered verbalisation in schizophrenia is a speech disturbance only or part of a disorder in thinking . LikewisThis data suggests that, as predicted, schizophrenia patients have problems in interpreting the thoughts of others, supporting the findings of previous work . The cloThere is however an alternative interpretation to these results. The individuals with schizophrenia may not be showing a domain -specific difficulty with ToM function but rather may be performing differentially more poorly than the control group on the more difficult ToM condition, such that the observed deficit could reflect a differential sensitivity to increased task difficulty.When the obtained totals for positive Krawiecka symptoms were analysed it was found that there was not a significant relationship between higher positive symptomatology and poor ToM performance, contrary to what had been predicted. Closer scrutiny of individual positive symptoms also revealed that neither delusions, hallucinations nor speech incoherence were significantly linked to an impaired ToM performance. Previous studies have shown paranoid delusions to be significantly related to poor ToM performance, in both first and second order ToM tasks and in both verbal and pictorial paradigms ,28 32].  32. 28] These findings might be attributed to several individuals who despite scoring the maximum Krawiecka score (4) for delusions, hallucinations or both, performed similarly to controls in the ToM condition.Alternatively, perhaps the nature of our patients' delusions and hallucinations may not be those specifically implicated in ToM impairment. Unfortunately, our sample size was too small to allow further investigation of patients with different types of delusion. Unlike the findings of previous research, negative features of schizophrenia were not associated with ToM capabilities. However, the mean Krawiecka scores for these features were low within the subject group, and our number of subjects was relatively small.This study was limited especially for symptom sub-groups analyses, by its relatively small sample size, although we did find disease effects. With a large sample, further symptom-specific sub-groups could be made . Furthermore, another control group of non-schizophrenia, psychiatric patients may have been useful to explore more closely the role of diagnosis as opposed to symptoms. One of our previous studies used a psychiatric control group of patients with a psychotic affective disorder and found that positive psychotic symptomatology was linked to poor ToM performance and was not diagnosis specific . This imWe believe that the Physical cartoons themselves acted as an adequate internal control. If the schizophrenia group had performed as poorly on the Physical cartoons as they did on the ToM cartoons, this could imply either a general verbalization deficit or a general cognitive impairment. Since this was not the pattern found, our results count against a domain-general interpretation of this type. Furthermore, as mentioned previously, regression analysis showed no significant effect of language impairment, as assessed using the Krawiecka symptoms of poverty of speech and incoherence of speech, on ToM joke performance. ANCOVA also showed that the group differences on the ToM jokes could not be accounted for by the group differences on the Physical jokes. This was taken as evidence for an observable and selective compromise of ToM capacity within the schizophrenia group.However, an unrelated cognitive neuropsychological task could have been implemented testing another cognitive domain (e.g. executive function, working memory) and this could have been used to further elaborate whether the observed compromised ToM function was a specific deficit or secondary to general cognitive impairment [see for example, 18–19 who used the Tower of London task in this way].Further research is then required in ToM and schizophrenia to see whether the presence of schizophrenia itself is enough to impair ToM capabilities or whether ToM impairment is due, instead, to presence of particular symptoms or presence of some general neuropsychological deficit. A further question that we did not address at all in the present study was whether the ToM deficits observed in schizophrenia could be state (related to fluctuating symptom severity) or trait in nature.The schizophrenia group performed significantly worse in both the Physical and ToM conditions on this visual joke task than the matched control group. The performance on the ToM condition was significantly worse and is taken as evidence for a compromised ToM capability in the schizophrenia group which is in keeping with previous research. In this instance poor ToM performance could not be significantly linked to any particular symptomatology as had been hypothesised.The author(s) declare that they have no competing interests.DM conceived and designed the study, collected neuropsychological test data and drafted the manuscript. HT helped implement the study and collect neuropsychological test data and co wrote first draft. DMac and DCO were involved in the psychiatric ratings of the patients and revisions of later drafts. PM advised on statistical analysis and helped to write the corresponding sections. SL supervised clinical aspects of study and revised later drafts and ECJ revised final draft and approved this version to be published.The pre-publication history for this paper can be accessed here:


There is an increasing prevalence of asthma in the Caribbean and patients remain non-compliant to therapy despite the development of guidelines for management and prevention. Some patients may self-medicate with medicinal herbs for symptomatic relief, as there is a long tradition of use for a variety of ailments. The study assessed the prevalence of use and the factors affecting the decision to use herbs in asthmatic patients attending a public specialty care clinic in Trinidad.de novo, pilot-tested, researcher-administered questionnaire between June and July 2003.A descriptive, cross-sectional study was conducted at the Chest Clinic in Trinidad using a Fifty-eight out of 191 patients (30.4%) reported using herbal remedies for symptomatic relief. Gender, age, ethnicity, and asthma severity did not influence the decision to use herbs; however, 62.5% of patients with tertiary level schooling used herbs, p = 0.025. Thirty-four of these 58 patients (58.6%) obtained herbs from their backyards or the supermarket; only 14 patients (24.1%) obtained herbs from an herbalist, herbal shop or pharmacy. Relatives and friends were the sole source of information for most patients (70.7%), and only 10.3% consulted an herbalist. Ginger, garlic, aloes, shandileer, wild onion, pepper and black sage were the most commonly used herbs.Among patients attending the Chest Clinic in Trinidad the use of herbal remedies in asthma is relatively common on the advice of relatives and friends. It is therefore becoming imperative for healthcare providers to become more knowledgeable on this modality and to keep abreast with the latest developments. Recent reports from the Caribbean suggest that the incidence of asthma is following the global trend of increasing prevalence. In Jamaica, a prevalence of 20.8% for exercise-induced asthma was estimated in a cross-sectional study in schoolchildren . About oInhaled corticosteroids as prophylaxis and 'as required' bronchodilator for symptomatic relief are established modalities for asthma management and prevention and the Commonwealth Caribbean Medical Research Council/Global Initiative for Asthma guidelines were adopted in the Caribbean in 1997 . It has Over the last few decades, a global resurgence in the use of herbal remedies has fuelled the growing multi-billion dollar international trade of botanical products. Many patients, dissatisfied with conventional medicines because they expect permanent cures, believe that herbal remedies are 'natural' and sometimes self-medicate without informing their attending physician.Although there is a long history of traditional use of medicinal herbs throughout the Caribbean ,8 few stThis study was undertaken to assess the extent of use of herbal remedies by asthmatic patients attending a specialty chest clinic in Trinidad for symptomatic relief and to determine the factors influencing the patient's decision to use herbs.The study was approved by the Ethics Committee of the Faculty of Medical Sciences, University of the West Indies, St. Augustine campus and permission to interview patients was granted by the Director of the Chest Clinic of the Ministry of Health, Trinidad and Tobago. The study was conducted over the two-month period June to July 2003.de novo, pilot-tested, researcher-administered questionnaire.The Chest Clinic was chosen as the source of subjects as this is the only national tertiary level health facility specializing in the management of respiratory diseases. Patients entering the study were physician-diagnosed asthmatics based on self-reporting symptoms of wheezing, chest tightness and nocturnal coughing in the previous year. Patients were recruited by consecutive sampling and the nature and purpose of the study were explained on an individual basis. Those confirming their willingness to participate signed their informed consent and were interviewed using a The questionnaire assessed demographic data such as age, gender, ethnicity, residential district, education, employment and socioeconomic status. Subjects reported their disease severity as intermittent, moderate or severe as determined by the Global Initiative for Asthma (GINA) guidelines with respect to symptom frequency . Patient2 tests were performed to determine whether there were statistically significant associations between the use of herbs and these variables. The p value was set at <0.05 for statistical significance. The data was analyzed using SPSS for Windows (Version 9.0, Chicago, IL).The sample size was calculated as 185 patients assuming a prevalence of 86%  with a cDuring the study period one hundred and ninety one patients consented to participate. The demographic details of the sample are given in Table 2-agonists (relievers) were prescribed at very high rates, Table 2-agonists. This high level of prescription and use of β2-agonists suggest a lack of symptomatic control in our sample population. Theophylline and anticholinergics were prescribed in both categories of patients, but to a lesser extent.The GINA guidelines were recently adopted in the Caribbean and asthmatic patients are currently treated according to their symptom severity. In our sample population, particularly in patients with moderate and severe symptoms, corticosteroids (controllers) and βGender, age, ethnicity, residential district, employment status, income and asthma severity had no statistically significant effect on the use of herbal remedies within the sample population, Table Most patients (70.7%) using herbs were advised by a relative or friend and only 10.3% sought the advice of an herbalist, Table Most patients (58.6%) obtained their herbs or medicinal plants from either their backyards or the supermarket. Only fourteen (24.1%) obtained their herbal supplies from an herbalist, herbal shop or pharmacy. Seventeen (29.3%) of these patients reported using herbs within the last week and most these patients (60.3%) used herbs within the last six months.Many of these patients were using both physician-prescribed antiasthmatic drugs and herbal remedies, Table Allium sativum) or ginger  for symptomatic relief of asthma, Table Aloe vera) shandileer (Leonotis nepetifolia), wild onion , pepper (Capsicum spp.) tulsi (Ocimum gratissimum), black sage (Cordia curassavica), shadon beni (Eryngium foetidium), lemongrass (Cymbopogon citratus) and nutmeg (Myristica fragrans) were the more popular traditional indigenous West Indian medicinal plants used. Two patients reported using marijuana (leaves and roots). Herbs of European and North American origin, identified as Echinacea (Echinacea purpurea), Golden Seal (Hydrastis canadensis) and Chamomile (Matricaria chamomilla) were less frequently used. Five patients reported using trade name imported tablets for asthma.Most patients in the sample used more than one medicinal herb simultaneously, which were usually prepared and administered as mixtures in teas. Almost one in four patients using medicinal herbs (22.5%) used either garlic  and aloes (Aloe vera), and traditional indigenous medicinal herbs such as shandileer (Leonotis nepetifolia) and tulsi (Ocimum gratissimum) were more likely to be earning less than US$12,000, Table Echinacea purpurea and Matricaria chamomilla) were more likely to be used by patients earning in excess of US$12,000 per annum. Income did not affect the use of either garlic or cocoa onion.Patients using easily accessible herbs such as ginger (Aloe vera), tulsi (Ocimum gratissimum) and golden seal were preferred in patients with at least twelve years of formal education, Table Leonotis nepetifolia), wild onion  or ginger .Aloes  were more expensive than conventional medicines. We assumed that an additional expense would have only been incurred by those patients purchasing processed, imported herbs obtained from a herbalist, herbal shop or pharmacy (24.1%) and who actually consulted a herbalist (10.3%). We also reasoned that since all the other herbs used were inexpensive and available from either the backyard garden or supermarket (58.6%) that the cost to patients selecting these remedies was minimal.The findings of this study are important in that local medicinal plants in Trinidad have been identified in the self-management of asthma in a significant number of patients attending the specialty clinic. These identified herbs can now be targeted for scientific investigation to determine whether their pharmacological efficacy will assist in the development of viable healthcare alternatives in a developing country. These findings are also important for policymakers in the health sector who are given the mandate to regulate issues pertaining to the public's health. We are also becoming more aware of the potential for critical interplay between herbs and drugs when taken concomitantly to produce life-threatening interactions. Since herbs are here to stay and patients will continue to self-medicate with increasing frequency, it is imperative that healthcare providers become more knowledgeable on this modality and keep abreast with the latest developments in herbal therapy.The author(s) declare that they have no competing interests.YNC was the P.I. in this study. He was responsible for the study concept, development of methodology, coordinating the research activities, analyzing the data, and writing the manuscript. AFW was responsible for data input and analysis. DA was involved in methodological development, data collection, data input and analysis and presentation at regional conference. RC was involved in methodological development, data collection, data input and analysis. NW was involved in methodological development, data collection and input. RM was involved in methodological development, data collection and input. OS was involved in methodological development, data collection and input. DW was involved in methodological development, data collection and input. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Escherichia coli sequences display the period close to 11 base pairs.Sequence periodicity with a period close to the DNA helical repeat is a very basic genomic property. This genomic feature was demonstrated for many prokaryotic genomes. The Escherichia coli. The noncoding sequences reveal this periodicity much more prominently compared to protein-coding sequences. The sequence periodicity of ApC/GpT, ApT and GpC dinucleotides along the Escherichia coli K-12 is found to be located as well mainly within the intergenic regions.Here we demonstrate that practically only ApA/TpT dinucleotides contribute to overall dinucleotide periodicity in E. coli suggests that the periodicity is a typical property of prokaryotic intergenic regions. We suppose that this preferential distribution of dinucleotide periodicity serves many biological functions; first of all, the regulation of transcription.The observed concentration of the dinucleotide sequence periodicity in the intergenic regions of  E. coli as well, is distributed in a non-uniform way, in scattered segments of the size 100–150 bases. It was also known for a long time that quite a few DNA promoter regions of E. coli possess the sequence periodicity of AA and TT dinucleotides [DNA sequence periodicity with the period about 10–11 base pairs (bp) has been long known in eukaryotic DNA sequences. It was discovered recently in prokaryotic sequences as well . The perE. coli promoters have upstream curved sequences [E. coli DNA curvature peaks are frequently located downstream of the CDS.The sequence periodicity of AA/TT dinucleotides is frequently associated with sequence-dependent DNA curvature, which is known to play an important role in the initiation of transcription of many genes (for reviews, see -15). Usiequences ,17. Pedeequences  showed tSince the dinucleotide periodicity with the period close to the helical repeat is associated with DNA intrinsic curvature -23, the E. coli and its distribution along the genome are systematically analyzed. A strong preference of intergenic regions to express the sequence periodicity of AA, AC, GC, and TT dinucleotides is discovered.In this work, the sequence dinucleotide periodicity in E. coli, as well as its coding and noncoding regions, was subjected to this procedure. Resulting autocorrelation profiles for all 16 dinucleotides (data not shown) were further analyzed by Fourier transform. In Fig. Positional autocorrelation analysis of the nucleotide sequences is an appropriate tool to detect all major characteristic distances in the sequences, the periodicities in particular. The complete genome of E. coli and find out where the periodical regions are located, we chose the period 11.2 bp [E. coli genome sequence and to detect the periodical sites. This calculation shows that the periodicity is not evenly distributed along the E. coli genome.To screen the genome of  11.2 bp  and this 11.2 bp ,26. We uE. coli genome are shown. The periodicity is distinctly located in certain regions. Many of the peaks observed are found to correspond to the intergenic regions (indicated by the black bars at the top). For example, two such peaks of periodicity in Fig. In Fig. To verify the apparent strong correlation between the intergenic regions and AA/TT periodicity, we split intergenic regions in several families by size and analyzed the subsets separately by aligning (centering) the regions and summing up the respective local periodicity distributions. The combined maps for intergenic regions with a size from 50 to 150 bp, from 150 to 250 bp, from 250 to 350 bp, from 350 to 450 bp, and from 450 to 550 bp are shown in Fig. E. coli DNA sequence periodicity.To verify the choice of the period 11.2 bases, we calculated the periodicity maps for highly populated group of the regions of the size 200 ± 50 bp, by assuming different periods in the range 10.5–12.5 bases. The resonance 3D plot in Fig. The spectral analysis Fig.  and examThe observed concentration of the sequence periodicity in the intergenic regions corroborates earlier results and suggests that the periodicity is a typical property of the intergenic regions.Escherichia coli K-12 MG1655, locus U00096, 4639221 base pairs, was taken from the National Center of Biotechnology Information . Intergenic regions were identified in accordance with the annotation to this genome of E. coli and gathered in a separate dataset.The sequence of the whole genome of X was calculated for each dinucleotide separately. For the calculation of ApA autocorrelation, for example, we calculated the number of occurrences of pairs ApA – ApA in a distance k, and designated it by Xk. Spectral analysis of autocorrelation profile X was obtained using the following formulae:Autocorrelation profile fp is normalized wave-function amplitude of period p, X is an autocorrelation profile for one chosen dinucleotide, Xi is its value in position i,  is its average value, and W is a maximal considered autocorrelation distance (in our case 100 bp).where T were taken to describe idealized periodical distribution of AA and TT dinucleotides within window W. The probes were correlated with E. coli sequences by moving the probes along the sequences and calculating the value C for every position.As a probe of periodicity the sine waves with period i is an index of a dinucleotide position in the window W andwhere Cmax is introduced for the normalization purposes. It is calculated as follows:The value i is a position in the window W andwhere C = 1, while segments with no periodicity would correspond to C = 0. The results of these calculations are presented as maps of the sequence periodicity. The four sample maps are shown in Fig. Ideally periodical sequence segments would be, therefore, described by The maps around intergenic regions were combined (summed) separately for the groups of similar sizes of the intergenic regions. Five such groups were analyzed: 100 ± 50 bp, 200 ± 50 bp, 300 ± 50 bp, 400 ± 50 bp, and 500 ± 50 bp. For each group the maps were synchronized at the respective intergenic centers and the sums of the maps were calculated and smoothed by a running average within 51 bp. The standard deviations for the combined plots were estimated by generating random sequences of the same size and dinucleotides composition for each group separately and averaging the respective periodicity maps.T in the interval 10–12.5 bp. One-third (202) of the most periodic maps of this group was taken for the calculation. The maps for different periods T were smoothed five times by a running average over 51 bp. The baselines were set to 0. The surface of 3D plot was smoothed 3 times by a running average over 9 point square elements, on the grid with separations 0.1 bp for T, and 20 bp for sequence position.The resonance 3D plot for the intergenic regions of length 200 ± 50 bp was built from calculations with different periods None declared.SH carried out all graphics. ENT and AB participated in the design of the study and analysis of results. All authors drafted the manuscript. All authors read and approved the final manuscript.


Fasciola hepatica primarily involves the liver, however in some exceptional situations other organs have been reported to be involved. The ectopic involvement is either a result of Parasite migration or perhaps eosinophilic reaction.Here we report a known case of multiple myeloma who was under treatment with prednisolone and melphalan. He was infected by Fasciola hepatica, which involved many organs and the lesions were mistaken with metastatic ones.Presented here is a very unusual case of the disease, likely the first case involving the pancreas, spleen, and kidney, as well as the liver. Human fascioliasis, a commonplace infection caused by a leaf-shaped Trematode Fasciolahepatica affects a human host by chance -4. It seIn Dec 2001, a 52 year old man, who was a known case of Multiple Myeloma (MM), was presented to one of our affiliated hospitals with persistent right upper quadrant and epigastric pain, and anorexia for a period of 1 month. At the time of admission, the patient had been receiving prednisolone and melphalan for his MM, which was currently in remission. His recent condition began with tongue and facial edema two weeks before appearance of the abdominal pain.Upon physical examination, mild epigastric tenderness and a palpable liver were found. Neither icterus nor any positive sign of cardiopulmonary abnormalities were noted. Additionally, the patient did not have a fever and his peripheral lymph nodes were not enlarged. Initial laboratory findings were as follows: a hemoglobin of 10.6 g/dL, white blood cell count of 10,800/mm3 with 18% eosinophils, and a sedimentation rate of 90 mm at the end of the first hour. The total bilirubin was 0.5 mg/dL (0.2–0.8 mg/dl), alanine aminotranferase (ALT) 48 IU/L (0–40 IU/L), aspartate aminotransferase (AST) 46 IU/L (0–40 IU/L), and alkaline phosphatase (Alk P) 651 IU/L (60–140 IU/L). The eosinophilia fluctuated between 12 to 55 percent in various tests performed during the time period in question, with no unique patterns noted. Serum electrophoresis showed a monoclonal spike in the gamma region. Specific enzyme-linked immunosorbant assay (ELISA) produced a positive result for Fasciola hepatica, while the test was negative for Toxocara canis. Serologic tests for the presence of hepatitis A, B, and C viruses were negative. Blood and urine cultures were found to be sterile. Other laboratory studies, including repeated stool examinations for ova and parasites, showed no abnormalities. Chest x-rays did not demonstrate any parenchymal or pleural abnormality. Abdominal ultrasonography showed a mild hepatomegaly with multiple hypoechoic lesions in the liver. A CT scan revealed multiple but poorly defined, hypodense lesions in the liver, and a completely enlarged pancreas with mild bilateral pleural reaction, suggesting metastatic cancer . In the search for a potential malignancy, diagnostic laprascopy was performed, which revealed the presence of white-colored lesions ranging from 1 to 3 cm in diameter on the surface of both lobes of the liver with mild ascites. Multiple liver and peritoneal biopsy specimens revealed fibrinoid necrosis, associated with granulomatous reaction and a high concentration of eosinophils in the liver,  accompanied by markedly inflamed peritoneal tissue with eosniphilic infiltration. No malignant cells were identified and no evidence of extramedulary plasmocytoma was found. Specific staining for fungal organisms and acid-fast bacilli were negative. The ascitic fluid also had a high level of eosinophils. Endoscopic retrograde cholangiopancreatography (ERCP) failed to show any filling defect within the biliary tree. Furthermore, the patient underwent bone marrow aspiration that only indicated high eosniophilic infiltration. The patient was placed on albendazole (400 mg twice daily for 1 week). The treatment was well tolerated and the abdominal pain was improved rapidly. At the time of discharge, the patient was in good clinical condition. During a follow-up visit two months later, a second CT unexpectedly showed not only an increase in the number and size of the hypodense lesions in the liver, but also the extension of lesions into the pancreas, the spleen and both kidneys . No evidence of peripheral enhancement of the hepatic lesions or ascites was documented. The patient was still experiencing upper quadrant pain on the right side. Laboratory investigations produced a white blood cell count of 7200/mm3 with 16% eosinophilia. Repeated stool examinations failed to identify ova and parasites. The patient was given triclabendazole (10 mg/kg, bid for two days). As recommended, the patient had another follow-up CT scan three months later. At that time all of his symptoms were resolved. Follow-up CT scans revealed a considerable improvement in the number and size of the lesions. At the time of the CT scan, all of his symptoms were resolved . At this time the WBC was 6000/mm3 with 6% eosinophils. After 5 months and in the last CT, the lesions had almost disappeared completely .While fascioliasis is a well-known human parasite, it sometimes produces unusual characteristics that may influence a clinician to misdiagnose the condition.In the vast majority of cases, the diagnosis is difficult in both acute and chronic phases and some important conditions such as liver abscesses and metastasis cannot be easily differentiated from fascioliasis ,13. InteAmong imaging tools, ultrasonography is of little diagnostic value during the acute phase, while a contrast-enhanced CT scan can be very useful for diagnosis ,17. In CAs clinical and laboratory findings of fascioliasis may easily be confused with many other conditions, a high index of suspicion is required to establish a correct diagnosis ,17. BothThe ingested metacercariae of Fasciola hepatica penetrate the intestinal wall and migrate through the peritoneal cavity to reach the liver. However, ectopic migration to other locations is one of the strangest manifestations of the infection ,9. The pThe pre-publication history for this paper can be accessed here:


The endometrium prepares for implantation under the control of steroid hormones. It has been suggested that there are complicated interactions between the epithelium and stroma in the endometrium during menstrual cycle. In this study, we demonstrate a difference in gene expression between the epithelial and stromal areas of the secretory human endometrium using microdissection and macroarray technique.The epithelial and stromal areas were microdissected from the human endometrium during the secretory phase. RNA was extracted and amplified by PCR. Macroarray analysis of nearly 1000 human genes was carried out in this study. Some genes identified by macroarray analysis were verified using real-time PCR.In this study, changes in expression <2.5-fold in three samples were excluded. A total of 28 genes displayed changes in expression from array data. Fifteen genes were strongly expressed in the epithelial areas, while 13 genes were strongly expressed in the stromal areas. The strongly expressed genes in the epithelial areas with a changes >5-fold were WAP four-disulfide core domain 2 (44.1 fold), matrix metalloproteinase 7 (40.1 fold), homeo box B5 (19.8 fold), msh homeo box homolog (18.8 fold), homeo box B7 (12.7 fold) and protein kinase C, theta (6.4 fold). On the other hand, decorin (55.6 fold), discoidin domain receptor member 2 (17.3 fold), tissue inhibitor of metalloproteinase 1 (9 fold), ribosomal protein S3A (6.3 fold), and tyrosine kinase with immunoglobulin and epidermal growth factor homology domains (5.2 fold) were strongly expressed in the stromal areas. WAP four-disulfide core domain 2 (19.4 fold), matrix metalloproteinase 7 (9.7-fold), decorin (16.3-fold) and tissue inhibitor of metalloproteinase 1 (7.2-fold) were verified by real-time PCR.Some of the genes we identified with differential expression are related to the immune system. These results are telling us the new information for understanding the secretory human endometrium. Many studies have sought to understand the mechanism of implantation. Recently, the rate of pregnancy in the in vitro fertilization and embryo transfer (IVF-ET) cycle has declined, and this has been attributed to a decrease in the rate of implantation. The recently developed laser microdissection method has gained widespread use throughout the research field. Information about cells can be determined without contamination by using this method. Moreover, with the macroarray technique, which was already widely used for this purpose, the profiling of the gene expression of specific cells types has become possible. Torres et al. have already reported differences in gene expression between cell types or regions within the monkey endometrium using laser microdissection and differential display ,2. Identification of cell-specific proteins, which are expressed in the endometrium during the secretory phase, has been performed using a multi-disciplinary approach in the same trial. IGF-II mRNA is expressed in the mid-to-late secretory phase and in early pregnancy . During In this study, we demonstrate differential in gene expression between the epithelial and stromal areas obtained from secretory human endometrium using laser microdissection and the macroarray method. Confirmation of differential expression of candidate genes was performed by real-time PCR. Human endometrium was obtained from 8 patients (25–38 years old) with normal menstrual cycles (28~30 days) during the mid secretory phase. These patients had had at least one intrauterine pregnancy in the past . Part of the endometrial biopsy was obtained with a curetting technique. The day of the menstrual cycle was determined by the patient's history, plasma progesterone levels (9.8~17.3 ng/ml) and the histological criteria of Noyes et al . These pThe endometrium was embedded in OCT compound and frozen immediately in isopentane that had been cooled in the liquid nitrogen. This freezing block was sliced by a cryomicrotome at 8 μm thickness. Frozen sections were fixed in 100% methanol for 3 min and stained with 1% toluidine blue. The section was laser-microdissected by the PALM MicroBeam system (PALM Microlaser. Technologies A.G.) for epithelial and stromal areas and collected in a small tube Fig . Approxi32P dCTP (3000 Ci/mmol) using a randam primer. Labeled probes were hybridized to a nylon array ) in ExpressHyb solution at 68°C overnight. After hybridization, the nylon membrane was washed with 2 × standard saline citrate (SSC) + 1% sodium dodecyl sulphate (SDS)  once, twice with 1.0 × SSC + 0.5% SDS at 68°C [The RNAs obtained were synthesized from cDNA using a modified oligo (dT) primer and the BD SMART™ PCR cDNA Synthesis Kit . cDNA was PCR amplified for 24–29 cycles according to the user manual. ). 550 ng of cDNA sample was labeled with α- at 68°C ,13. The  at 68°C ,15. In tRNA was reverse transcribed using oligo (dT) primers by TaKaRa RNA PCR Kit (AMV) Ver 2.1 (TAKARA BIO INC, Shiga, Japan) according to the manufacturer's instructions. PCR was performed using the ABI PRISM 7700 Sequence Detection System. TaqMan Universal PCR MasterMix and Assays-on-Demand Gene Expression probes (Applied Biosystems) were used for the PCR step . Primer sequences are not publicly available, although their validity has been established by the manufacturer. The expression values obtained were normalized against those from the control human GAPDH [Secretory endometrium was collected from 8 patients . Each sample was carefully dissected by laser microdissection for epithelial and stromal areas Fig  to 1d.Total RNA was extracted and subjected to macroarray with nearly 1000 genes on the nylon membrane. Fifteen genes were strongly expressed in the epithelial areas Table . Mean vaReal-time PCR  was used to verify the changes in expression of certain candidate genes that are highly expressed in the array. Five samples were used for this study. WFDC2 and MMP7, which are both strongly expressed in the epithelial areas and decorin and TIMP1, which are both strongly expressed in the stromal areas by the cDNA array were chosen for verification. Each value was corrected for differences in loading relative to GAPDH mRNA expression. WFDC2 and MMP7 mRNA expression increased by 9.4- and 9.7-fold, respectively, compared to that of stromal cells. Decorin and TIMP1 mRNA expression increased by 16.3-and 7.2-fold, respectively, in stromal cells compared to that of epithelial cells. Statistically significant changes in expression of these genes were observed (p < 0.05) Fig  and 2D.in vivo. It has recently become possible to acquire the information about the cell by the microdissection method. To date, various methods have been used for understanding the function of the endometrium. It is a well-known fact that epithelial cells and stromal cells in the endometrium play specific roles and are influenced by steroid hormones. However, it is very difficult to understand the molecular composition of each cell type as a function of time during the menstrual cycle. One of the problems of a cell culture experiment is that separation cultivation makes changes the composition of the cells. This is especially true as these cells are influenced by neighboring cells In this study, laser microdissection was used to isolate epithelial and stromal areas from the human endometrium. RNA was amplified by PCR and global gene expression was demonstrated by cDNA macroarray. Twenty-eight genes were identified in this study. These constitute only 2.8% of the 1000 genes on the array. Although this seems to be a small number, these genes were expressed at least 2.5-fold greater in all three samples and normalized to two house keeping genes. A similar percentage (1.2–5.8%) of genes with differential expression were reported using array analysis -19. HoweRecently, some papers focused on endometrial gene expression have been reported. However, lots of them were compared between phases in the menstrual cycle. While Okulicz et al. demonstrated a difference in the gene expression between cell compartments in the monkey endometrium, the genes they identified are not the same as ours ,2. One oFifteen of 1000 genes were strongly expressed in the epithelial areas compared to the stromal areas. Of these, WFDC2 and MMP 7 were strongly expressed in the epithelial areas as confirmed by real-time PCR. WFDC2 was originally described as an epididymis-specific protein is expressed in a number of normal human tissues. A possible role for this gene in sperm maturation is indicated by amino acid similarities to extracellular proteinase inhibitors of genital tract mucous secretions . AlthougHOXB gene induction is related to the immune system, and is specifically associated with IL-2-induced NK cell proliferation ,28. AlthOf the strongly expressed genes in the stromal aeas, decorin and TIMP1 gene expression were verified by real-time PCR. San Martin et al. reported the expression of decorin which is a leucine-rich proteoglycan in the mouse uterine and suggested it localized in the undifferentiated interimplantation site stroma . Some re