Plasmodium ovale and Plasmodium malariae have long been reported to be widely distributed in tropical Africa and in other major malaria-endemic areas of the world. However, little is known about the burden caused by these two malaria species.P. ovale and P. malariae clinical attacks. The prevalence of P. ovale and P. malariae infections in asymptomatic individuals were high during the first years of the project but decreased after 2004 and almost disappeared in 2010 in relation to changes in malaria control policies. The average incidence densities of P. ovale and P. malariae clinical attacks were 0.053 and 0.093 attacks per person per year in children <15 years and 0.024 and 0.009 attacks per person per year in adults ≥15 years, respectively. These two malaria species represented together 5.9% of the malaria burden.We did a longitudinal study of the inhabitants of Dielmo village, Senegal, between June, 1990, and December, 2010. We monitored the inhabitants for fever during this period and performed quarterly measurements of parasitemia. We analyzed parasitological and clinical data in a random-effect logistic regression model to investigate the relationship between the level of parasitemia and the risk of fever and to establish diagnostic criteria for P. ovale and P. malariae were a common cause of morbidity in Dielmo villagers until the recent dramatic decrease of malaria that followed the introduction of new malaria control policies. P. ovale and P. malariae may constitute an important cause of morbidity in many areas of tropical Africa. Plasmodium ovale and Plasmodium malariae have long been reported to be widely distributed in tropical Africa and in other major malaria-endemic areas of the world P. malariae and 4–10% for P. ovale in studies where thick blood films were carefully examined by trained microscopists since parasitemia is usually low Anopheles breeding sites, P. falciparum is always highly endemic, and most P. ovale and P. malariae infections are associated with P. falciparum infections P. ovale and P. malariae are much lower, rarely exceeding 1% for P. ovale and 10% for P. malariaeP. ovale and P. malariae infections in endemic populations are poorly known, and most clinical data come from studies conducted in non-immune travelers returning from endemic areas or in patients that were given malaria therapy for the treatment of neurosyphilis during the period 1920–1960. High fever is the main symptom, attacks are mild and severe complications appear very rare P. falciparum, possibly due either to underdiagnosis of P. ovale and P. malariae clinical attacks, to partial cross-immunity between malaria species, or to rapidly acquired species-specific protective immunity against P. ovale and P. malariae. In the literature, there is little evidence that P. malariae may be responsible for fever episodes in children or adults living in highly malaria endemic areas, but the occurrence of fever episodes temporally related to peaks of P. malariae parasitemia was reported in Liberia P. ovale in fever episodes has been clearly established in Senegal both in children and in adults, but the incidence of the disease was much lower than for P. falciparumThe clinical features of P. malariae and P. ovale infections that we collected over a 20-year period in this population.In 1990, a longitudinal prospective study of malaria infection and the determinants of the disease was set up in the population of Dielmo village, a holoendemic area of Senegal The project was initially approved by the Ministry of Health of Senegal and the assembled village population, and renewed on a yearly basis. Written informed consents were obtained individually from all participants or the parents of children younger than 15 years. For children participants aged 15–18 years, written informed consent were obtained individually since the National Ethics Committee of Senegal considered that participants in this age are responsible for their own person. Audits were regularly carried out by the National Ethics Committee of Senegal and ad-hoc committees of the Ministry of Health, the Pasteur Institute , and the Institut de Recherche pour le Développement .The study was carried out from June 1990 to December 2010 in Dielmo, a village situated in a Sudan-savannah region of central Senegal. It is an area of intense and perennial transmission where the mean entomological inoculation rate was 258 and 132 infected bites per person per year during 1990–2006 and 2007–2010 periods, respectively Four first-line antimalarial treatment were successively used during the 20 years study period: oral quinine (Quinimax®) (October 1990 – December 1994), chloroquine (January 1995 – October 2003), sulfadoxine/pyrimethamine + amodiaquine (SP+AQ) (November 2003 – May 2006) and artesunate + amodiaquine (AS+AQ) (June 2006 – December 2010). In most patients, antimalarials were given only in case of fever with a parasite/leukocyte ratio >2. At the beginning of the project, 48.6%  of the villagers used traditional mosquito nets, which were untreated, and this proportion remained almost unchanged until July 2008 when long-lasting insecticide-treated nets (LLINs) were distributed to all villagers.Plasmodium species presented in this study were those observed from 1990 to 2010 during bi-weekly (June–September 1990) or quarterly cross-sectional surveys . All measurements of parasitemia  were taken into account, even if fever or other symptoms were documented at the same period.Prevalence rates for each P. ovale and P. malariae infections are asymptomatic. To distinguish the episodes of fever caused by P. ovale or P. malariae from those caused by other diseases when these parasites were present by chance, the relationship between parasitemia and fever was investigated by a case-control approach then the occurrence of age-dependent pyrogenic thresholds was investigated by a logistic regression method. A total of 64,284 simultaneous measurements of parasitemia and temperature made from June 1990 to December 2010 among 760 individuals aged from one month to 99 years were included in the analysis. The following definitions of case and control observations were used:In persons living in areas where malaria is endemic, most Individual observations were regarded as fever cases if the rectal temperature measured by active case detection at home or by passive case detection at the clinic was ≥38°C (young children) or the axillary temperature was ≥37.5°C (older children and adults). Two fever episodes were considered independent if they occurred fifteen days apart or more. When several simultaneous measurements of parasitemia and temperature were available for the same fever episode, only the highest measure of parasitemia and the temperature associated were taken into account. 14,841 observations of parasitemia and temperature matched the case definition.Owing to the erratic nature of hyperthermia during malaria attacks and a number of other diseases, individual observations from the cross sectional surveys were considered to be asymptomatic controls if rectal/axillary temperatures were lower than 38°/37.5°C and if there was no episode of illness  between fifteen days prior and seven days after the temperature was taken. Measurements from pregnant women were excluded from the analysis. 49,443 simultaneous measurements of parasitemia and temperature performed during bi-weekly, weekly, monthly or quarterly cross-sectional surveys matched the control definition.P. falciparum parasitemia ij that the individual i presented a febrile episode during the observation j was expressed in the form of a linear function of age zi and parasite density xij. The best fit was obtained using a series of three dummy variables zik where k was an index coding for the four following age groups: 0–1, 2–6, 7–12, and ≥13 years old and using the rth power of x for the parasitemia. A threshold value in addition to the previous continuous effect of parasitemia was introduced as a binary variable sij and improved the goodness of fit of the model. The pattern of the threshold depending on age and parasitemia, the parameters used and the equation obtained was described previously 0 was a constant, αi was the random-effects individual terms, β1, β2 and β3 were the regression coefficients.Since parasite prevalence and the occurrence of fever cases associated with the presence of malaria parasites decreased considerably during the most recent years, age-dependent pyrogenic threshold were investigated separately for the periods 1990–2004, 2005–2007, and 2008–2010. The method to calculate the age-dependent pyrogenic threshold by a random-effect logistic regression model of age and parasitemia was described earlier for The models for each study period were compared according to the maximum likelihood (minimum deviance) using the Akaike method by minimizing the Akaike criterion P. ovale and P. malariae clinical attacks were defined as any case with fever or allegation of fever and/or fever-related symptoms whose parasitemia was higher than the age and period corresponding threshold value of each species derived from the model  or the case-control study . Two clinical attacks were counted separately if they occurred fifteen days apart or more. When P. falciparum associated parasitemia was higher than the age and period corresponding threshold of this species P. falciparum only was attributed, even in the few cases where P. ovale or P. malariae parasitemia thresholds were reached simultaneously. However, when distinct peaks of high parasitemia involving two malaria species were successively observed within fifteen days and the threshold was reached for each species, the fever episode was attributed to both malaria species.For incidence density calculation, P. ovale (2.5%), 3,584 P. malariae (12.2%), and 13,216 P. falciparum (45.1%) infections with the parasite alone or in association. There were 2,912 mixed infections, including 2,320 P. falciparum/P. malariae, 314 P. falciparum/P. ovale, 12 P. ovale/P. malariae, and 266 P. falciparum/P. malariae/P. ovale associations.From 1990 to 2010, of 29,280 thick blood films realized during bi-weekly (June-September 1990) or quarterly cross-sectional surveys (from November 1990 to 2010), 14,341 (49.0%) were found positive for the presence of one or several malaria species, including 719 Plasmodium species from 1990 to 2010. P. falciparum prevalence was always higher than the prevalence of the two other species, and P. malariae prevalence was always higher than P. ovale prevalence. For all species, there was a marked decrease in prevalence during the most recent years. P. ovale prevalence by year and age group. There were important annual variations in all age groups, with marked peaks in 1990, 1999 and 2001 reaching up to 7–13% in several age-groups in children. However, P. ovale almost disappeared after 2004. As shown in P. malariae prevalence was very high (≈40%) in children during the first years of the project. The following years, prevalence declined markedly in young children, but remained high and almost unchanged until 2004 in older children and adults. There was a marked decrease in 2005–2009 and this species almost disappeared in 2010.P. ovale symptomatic and asymptomatic parasitemia according to age group between 1990 and 2010. Considering the changes in P. ovale prevalence during the 20 years of follow up, the relationship between P. ovale parasitaemia and the occurrence of fever was investigated separately during two different periods: from June 1990 to December 2004, and from January 2005 to December 2010.P. ovale parasitemia and the occurrence of fever during the period 1990–2004 is presented in P. ovale. Of 37,074 observations among asymptomatic persons, 818 (2.2%) involved subjects infected by P. ovale. There was more fever cases with P. ovale associated with other Plasmodium species  than fever cases with P. ovale only . Risk of fever increased by 10-fold when P. ovale parasitemia was above 800/µl of blood (p<0.001). Above 4,000 parasites per µl of blood, only 3 (2.0%) P. ovale infections were asymptomatic and the 146 other infections (98.0%) presented fever. Maximum P. ovale parasitemia observed during a fever episode was 88,320/µl in a 4 year old child  and the maximum parasitemia without documented symptoms was 5,040/µl in a 4 year old child.The relationship between P. ovale parasitemia and the occurrence of fever during the period 2005–2010 is presented in P. ovale and three of these cases  corresponded to infections with P. ovale only, the fourth case (parasitemia 7/µl in a 7 year old child) being associated with P. falciparum. Risk of fever increased by 13-fold when P. ovale parasitemia was above 800/µl of blood (p<0.001). Of 12,369 observations in asymptomatic persons, only 10 (0.08%) involved persons infected by P. ovale and parasitemia ranged from 2 to 960/µl.The relationship between P. malariae symptomatic and asymptomatic parasitemias according to age group between 1990 and 2010. Considering the changes in P. malariae prevalence during the 20 years of follow up, the relationship between P. malariae parasitemia and the occurrence of fever was investigated separately during three different periods: from June 1990 to December 1994, from January 1995 to December 2004 and from January 2005 to December 2010  involved persons infected with P. malariae. They were more fever cases with P. malariae associated with P. falciparum and/or P. ovale  than fever cases with P. malariae only . The risk of fever increased moderately when P. malariae parasitemia was higher than 3,000/µl or 6,000/µl of blood. All infections were symptomatic when parasitemia was higher than 8,500/µl of blood. Maximum P. malariae parasitemia observed during a fever episode was 16,560/µl in a 4 year old child  and the maximum parasitemia without documented symptoms was 8,400/µl in a 3 year old child.During the first period (1990–1994), 797 (27.1%) of 2,938 fever cases occurred in patients infected by P. malariae. Of 20,289 observations in asymptomatic persons, 1,862 (9.2%) involved persons infected with P. malariae. They were more fever cases with P. malariae associated with P. falciparum and/or P. ovale  than fever cases with P. malariae only . The risk of fever increased 6-fold when P. malariae parasitemia was above 3,000/µl of blood (p<0.001). Above 6,000/µl of blood, only 6 infections (18.7%) were asymptomatic. Maximum P. malariae parasitemia observed during a fever episode was 31,840/µl in a 3 year old child  and the maximum parasitemia without documented symptoms was 8,960/µl in a 3 year old child.During the second period (1995–2004), 951 (10.3%) of 9,244 episodes of fever occurred in patients infected by P. malariae. Of 12,369 observations in asymptomatic persons, 267 (2.2%) involved persons infected with P. malariae. There was little difference between the number of fever cases associated with P. malariae in mixed infections  and the number of fever cases with P. malariae only . The risk of fever increased 9-fold when P. malariae parasitemia was above 3,000/µl of blood. Maximum P. malariae parasitemia observed during a fever episode was 8,240/µl in a 7 year old child  and the maximum parasitemia without documented symptoms was 6,560/µl in a 9 year old child.During the third period (2005–2010), 85 (3.2%) of 2,659 episodes of fever occurred in patients infected by P. malariae parasitemia during the three periods 1990–1994, 1995–2004 and 2005–2010 are shown in The age-dependent pyrogenic threshold levels of P. ovale and 290 to P. malariae.Over the 20 years of study, there were 22,266 episodes of fever or fever-related symptoms during the 2,110,321 person-days of clinical monitoring of the study population . 219 clinical malaria attacks were attributable to P. ovale attacks were observed in 155 persons from all compounds of the village . Of the 38 individuals with two attacks, 18 presented their second attack within twelve months after the first attack (13 within six months). Of the 11 individuals with three or more attacks, 10 presented all attacks  or all attacks except one  within a twelve month period between two successive attacks, and one individual with three attacks had all attacks separated by at least two years each. The youngest child who presented P. ovale clinical malaria was a 2 month-old infant and the oldest was a 89 year old man. The median parasitemia reached during the 219 attacks was 8,426/µl. A temperature below 38°C  or 37.5°C (axillary) with fever-related symptoms only was observed in 40 attacks. A temperature ≥39°C was documented in 126 attacks. The average incidence density of P. ovale attacks at the community level from 1990 to 2010 was 0.04 attacks per person per year. P. ovale attacks was maximum in 1999, reaching 0.17 attacks per person per year, and minimum in 2007, 2009 and 2010 where no attack was observed. P. ovale clinical attacks according to age during the whole study period. 151 of 219 cases (68.9%) occurred in children under 15 years-old and the mean incidence density was maximum in children 5–9 years where it averaged 0.07 attacks per child per year. Maximum incidence density in a given year and age group was observed in 1999 in children 0–4 year who presented 0.32 attacks per child. A total of 68 of 219 cases (31.1%) occurred in adults, including 28 cases (12.8%) in adults ≥30 years old. The incidence density was only 2.4 fold lower in adults ≥15 year (0.023 per year) than in children <15 year (0.054 per year). P. ovale attacks occurred all year round, without marked seasonal pattern .P. malariae attacks were observed in 131 persons from all compounds of the village . Of the 29 individuals with two attacks, 16 presented their second attack within twelve months after the first attack (13 within six months). Of the 40 individuals with three or more attacks, 34 presented all attacks  or all attacks except one  within a twelve month period between two successive attacks, and six individuals with three attacks or more had from three to five attacks separated by at least one year. The youngest child who presented P. malariae clinical malaria was a 2 month-old infant and the oldest was a 42 year old man. The median parasitemia reached during the 290 attacks was 4,167/µl. A temperature below 38°C  or 37.5°C (axillary) with fever-related symptoms only was observed in 34 attacks. A temperature ≥39°C was documented in 188 attacks. The average incidence density of P. malariae attacks at the community level from 1990 to 2010 was 0.05 attacks per person per year. P. malariae attacks was maximum in 1998, reaching 0.11 attacks per person per year, and minimum in 2009 and 2010 where no attack was observed. P. malariae clinical attacks according to age during the whole study period. 265 of 290 cases (91.4%) occurred in children under 15 years-old and the mean incidence density was maximum in children 5–9 years where it averaged 0.15 attacks per child per year. Maximum incidence density in a given year and age group was observed in 2002 in children 5–9 year who presented 0.39 attacks per child. A total of 25 of 290 attacks (8.6%) occurred in adults, including 8 attacks (2.8%) in adults ≥30 years old. The incidence density was 12 fold lower in adults ≥15 year (0.008 per year) than in children <15 year (0.096 per year). P. malariae attacks occurred all year round, without marked seasonal pattern .P. ovale and P. malariae in malaria endemic areas of tropical Africa. Although many comprehensive studies have investigated P. falciparum malaria both in patients attending clinics and in cohort population studies where the occurrence of clinical malaria episodes was closely monitored, generally no information was published regarding data collected on P. ovale and P. malariae during these studies. Several reasons may explain the rarity of published works on these two malaria parasites, including the low incidence of the disease, and -due to the lack or rarity of severe cases- its much lower importance than P. falciparum in terms of public health, but also the practical difficulties of such studies that need specifically trained microscopists  and may require specific data analysis methods since P. ovale and P. malariae are often associated with P. falciparum at various but often very low levels of parasitemia.Few studies have attempted to measure the burden P. ovale between 1990 and 2004, which clearly presented strong annual variations independent of treatment policies. It would have been interesting to know if both (sub) species of the P. ovale complex  and five among children with parasitemia ranging from 1,650 to 5,935/µl . In our study, in contrast to P. falciparum and P. ovale, P. malariae attacks in each age group were often associated with levels of parasitemia only scarcely higher than levels of parasitemia commonly observed during asymptomatic infections. In the case of P. ovale, we presented in a previous paper an analysis of the relationship between parasitemia and fever in Dielmo during the period 1990 to 1996 using a case control approach P. ovale attacks, i.e. 42 attacks more than the 219 attacks measured by the age-dependent threshold-effect model, most of these additional attacks occurring in children under 10 years.In malaria endemic areas, where asymptomatic infections are highly prevalent, the detection of malaria parasites in persons with fever is not sufficient criteria for distinguishing malaria from other causes of fever. Methods based on parasite density are widely used to confirm or discard the diagnosis of P. ovale and P. malariae attacks in Dielmo population was much lower than the incidence of P. falciparum attacks. Using a similar model, 7,978 P. falciparum malaria attacks were diagnosed between October 1990 and December 2010 P. ovale and P. malariae attacks were mild and of short duration, but fever was often high and one P. ovale attack was responsible for a stillbirth. P. malariae was more involved than P. ovale in mixed infections with P. falciparum, even at high parasitemia. There were 7 attacks due to P. ovale and 3 attacks due to P. malariae within 15 days of a P. falciparum clinical attack.The incidence of P. ovale and P. malariae first infections and attacks in infants were observed during the third month of life, although the mothers of these infants have spent much of their life under high transmission conditions, suggesting that materno-transmitted immunity was insufficient to prevent infection and disease, this in particular when there was no pre-existing P. falciparum infection. In children, the incidence of P. ovale and P. malariae attacks was much lower than expected from data on incidence  or prevalence  of patent infections as measured by bi-weekly, weekly or monthly microscopy P. falciparum asymptomatic infections was maximum. The duration of patent infections was much shorter for P. ovale than for P. malariae and the dynamics of parasitemia differed , but this was less the case for P. malariae attacks. Furthermore, no marked peak of parasitemia was observed for most P. malariae attributed clinical attacks, and since most P. malariae infections were long lasting with often high levels of chronic parasitemia in several children, it remains unclear to what extent our model was able to provide accurate measurements of P. malariae morbidity for all individuals. The two children who were attributed 13 and 9 P. malariae attacks were permanent resident of Dielmo and suffered these attacks between ages 2–13 years and 7–13 years, respectively.Although an analysis of interaction between malaria species and the presumed respective roles of species-specific and cross immunity is out of the scope of this paper, some observations are of interest. Both P. ovale clinical attacks occurred among adults, versus only 8.6% for P. malariae. For both species a high proportion of clinical attacks occurred among permanent residents of Dielmo. On average, the mean incidence density of clinical attacks in adults was 2.9 fold higher for P. ovale (0.023 attacks per person per year) than for P. malariae (0.008 attacks per person per year). These results suggest that at least for some individuals continuously exposed since birth to many reinfections by P. ovale and P. malariae, acquired immunity may be lost or insufficient to prevent any clinical attack. However, as also observed for P. falciparum attacks, the duration of fever and other symptoms rarely exceeded one or two days, even when no antimalarials were given Almost one third (31.1%) of P. malariae have been reported in the literature P. malariae . In the case of P. ovale, life-threatening illness may also occur at least occasionally, as recently reported in a non-immune traveler returning from Nigeria Chronic nephrotic syndromes attributed to P. ovale and P. malariae were a relatively common cause of morbidity in most age groups, including adults, until the recent dramatic decrease of malaria that followed the introduction of new control policies combining ACTs and LLINs. P. ovale and P. malariae may remain an important cause of morbidity in many areas of tropical Africa.Although representing together only 5.9% of the whole malaria morbidity among Dielmo villagers,


Caloric intake among children could be reduced if sugar-sweetened beverages were replaced by plain water. School drinking water infrastructure is dictated in part by state plumbing codes, which generally require a minimum ratio of drinking fountains to students. Actual availability of drinking fountains in schools and how availability differs according to plumbing codes is unknown.We abstracted state plumbing code data and used the 2010 YouthStyles survey data from 1,196 youth aged 9 through 18 years from 47 states. We assessed youth-reported school drinking fountain or dispenser availability and differences in availability according to state plumbing codes, sociodemographic characteristics, and area-level characteristics.P < .01) by race/ethnicity, census region, the fountain to student ratio specified in plumbing codes, and whether plumbing codes allowed substitution of nonplumbed water sources for plumbed fountains. “Widely available” fountain access ranged from 45.7% in the West to 65.4% in the Midwest and was less common where state plumbing codes required 1 fountain per more than 100 students (45.4%) compared with 1 fountain per 100 students (60.1%) or 1 fountain per fewer than 100 students (57.6%).Overall, 57.3% of youth reported that drinking fountains or dispensers in their schools were widely available, 40.1% reported there were only a few, and 2.6% reported that there were no working fountains. Reported fountain availability differed significantly (Interventions designed to increase consumption of water may want to consider the role of plumbing codes in availability of school drinking fountains. Americans can limit excess caloric intake and weight gain by drinking water and other beverages with few or no calories  and caloProviding greater access to free drinking water in schools is a strategy to support healthy beverage intake among youth ,7. The IWe used the 2010 YouthStyles survey, which was administered by Synovate, Inc, a market research firm. This national mail survey assessed health-related attitudes and behaviors among children. Participants were selected from children of respondents to the ConsumerStyles survey, a consumer mail survey drawn from a mail panel of 200,000 potential respondents. The sampling design is stratified by region, household income, population density, age, and household size and includes an oversample of low-income and minority participants and households with children to ensure adequate representation of these groups. In 2010, a total of 10,328 people completed the ConsumerStyles survey .Following survey completion by ConsumerStyles participants, 2,401 YouthStyles surveys were sent to a stratified sample of adults with children aged 9 through 19 years living at home, with instructions that the sampled youth should complete the survey. Of the 2,401 YouthStyles surveys sent, 1,197 surveys were completed, yielding a youth response rate of 49.9%. Respondents were youth from 47 states and the District of Columbia. Alaska, Hawaii, and Wyoming were not represented in the study population. The YouthStyles survey is weighted to match the US Current Population Survey . Individ2 test, P = .001) and parent race/ethnicity (P < .001). Higher response rates were seen among high school–aged youth (55%) compared with middle school–aged (50%) and elementary school–aged (48%) youth. Lower response rates were seen among Hispanics (37%) compared with non-Hispanic (NH) whites (55%) and NH blacks (52%).There were no statistical differences in YouthStyles responders and nonresponders by parental income, home ownership, household size, or sex of child. However, response rates differed by child age  as noted above, 2 categories were created for the water access variable: 1) drinking fountains widely available, and 2) few or no working drinking fountains.We included in our analysis demographic variables of sex, race/ethnicity , age , and annual household income . Cutpoints for annual household income approximately correspond to 100% and 250% income to poverty level ratios for a family of 4.Respondents were classified by the respondent’s state of residence according to the following 4 US Census regions: Northeast, South, Midwest, and West . The sizwww.iccsafe.org) and Reed Construction Data (www.reedconstructiondata.com) to determine whether a particular state had adopted a statewide plumbing code. Next, we conducted state-by-state searches using the Westlaw legal database of state administrative codes (www.westlaw.com) to identify codified plumbing code provisions and extract citations. If a model code or other statewide plumbing code was adopted, we determined whether it was applicable to school buildings and whether the code had been modified. We also searched state department of education regulations for the terms “water” and “drinking fountain” and state department of health regulations for “drinking fountain” and “school facilities” in reference to statewide plumbing codes.Plumbing code data for each state were obtained through legal research of each state during 2012. First, we consulted online data available from the International Code Council (www.iccsafe.org/cs/PMG/Pages/IPC.aspx]) that are not mandatory but rather optional for local jurisdictions to adopt. Some states have school-specific provisions that allow the use of a local building code or a model building code. In all these cases, the school drinking fountain standard that was contained in a referenced model code was used. Statewide building codes could not be abstracted in Mississippi and Missouri because neither state adopted statewide plumbing codes setting minimum fountain standards.With the exception of Arkansas, where the school fountain requirement was repealed 1 month before code abstraction, the codes referenced are the codes that were in effect as of August 2012. If school-specific plumbing provisions differentiated between “existing” and “new” buildings, the fountain requirement for “new” facilities was used. Several states recognize model codes . First, univariate frequencies of perceived school drinking fountain access were estimated. Next, bivariate analysis was performed to assess differences in prevalence of widely available school drinking water access according to age, sex, race/ethnicity, household income, region, metropolitan status, the fountain to student ratio specified in the plumbing code, and whether the plumbing code allowed nonplumbed water dispensers. Because all state plumbing codes that specify fountain to student ratios of 1 fountain per more than 100 students also do not allow substitution of plumbed drinking fountains, and because nearly all observations in the data set corresponding with fountain to student ratios of 1 fountain per more than 100 students occur in the West, it was not possible to include these 3 variables  in the same model. Therefore, 3 multivariable logistic models were fit after controlling for age, sex, race/ethnicity, household income, and metropolitan status. This analysis was exempt from the Centers for Disease Control and Prevention (CDC) Institutional Review Board process because personal identifiers were not included in the data provided to CDC.Overall, 57.3% of respondents reported that school drinking fountains or dispensers were widely available, 40.1% reported there were only a few, and 2.6% reported that there were no working fountains available in their schools. Statewide plumbing codes for school buildings are shown in Perceived school water access differed by race/ethnicity, region, fountain to student ratio specified in the plumbing code, and allowance of nonplumbed water dispensers . Widely In multivariable analysis, black youth were more likely to report widely available fountains or dispensers compared with white youth . Youth living in the Midwest  and South  were significantly more likely to report widely available school drinking fountains than youth in the West. Youth living in states where plumbing codes required 1 fountain per more than 100 students were significantly less likely  to report widely available drinking fountains than youth residing where plumbing codes specified 1 fountain per 100 students. Compared with youth residing where nonplumbed drinking fountains were not allowed, youth residing in states where 100% or 50% substitution of plumbed fountains with nonplumbed water dispensers was allowed were significantly more likely to report widely available drinking water fountains or dispensers  .We found that more than 40% of youth reported that there are few working drinking fountains or dispensers available in their school, and 1 in 25 youth reported there are no working fountains or dispensers. We also found regional differences in youth-reported access, with reported access lowest in the West and highest in the Midwest. These differences may be partially due to state plumbing codes, which differ greatly by region. To our knowledge, this is the only study to examine school drinking water access at a national level or to examine the association of state plumbing codes with water access in schools.Increasing free drinking water access in schools is gaining greater attention as a means of encouraging healthy beverage intake among children, with recent regulatory requirements implemented at both the state and federal level ,14. DataOur study suggests that water access may be greater where plumbing codes require at least 1 drinking fountain per 100 students and where codes allow the substitution of nonplumbed water dispensers for plumbed drinking fountains. However, the clustering of these 2 attributes in state plumbing codes because of widespread adoption of published model codes makes it difficult to separate the effects of fountain to student ratio and allowing nonplumbed water fountains to be substituted for plumbed water fountains. Specifically, all state plumbing codes that specify fountain to student ratios of 1 fountain per more than 100 students also do not allow any substitution for plumbed drinking fountains. Although 3 non-Western states specify fountain to student ratios of 1 fountain per more than 100 students , the small samples from these states limited our ability to separate the effect of plumbing codes on school water availability from that of region.Regional factors other than plumbing codes could explain regional differences. In general, the arid climate of many Western states can create challenges in ensuring adequate drinking water supplies for their populations and may thus encourage an atmosphere of water conservation that overrides access concerns . Water qThis study has several limitations. First, we could not separate the effects of plumbing codes from those of region. Second, we used youth-reported drinking fountain access, from a survey offered only in English, rather than objective measurement. Future research is needed on how student-reported water access corresponds to actual access and to validate water access survey items. Third, we did not have information on local municipal plumbing codes or school wellness policies, which may go beyond state plumbing codes in specifying water access requirements in schools. Fourth, we did not have data on the age of the school facilities. Age of school facilities may be a factor in how plumbing codes associate with actual water access, because codes may change over time and broken fountains may come out of service and not be replaced. Furthermore, water access may change over time as the number of students attending a school changes and schools undergo additions or renovations that either add or remove fountains. Finally, because of selection bias associated with the use of a convenience sample from a mail panel survey and a low response rate, our findings may not be generalizable nationally. However, the study population included participants from 47 states and the District of Columbia who were sampled proportionately to state populations, and participants were weighted to match the US Current Population Survey . A previWe found that 4 in 10 youth report that there are only a few working drinking fountains or dispensers in their schools, and 1 in 25 indicated that they had no working fountains or dispensers in their school. Additionally, student-reported drinking fountain availability, after controlling for other factors, was significantly different by race/ethnicity, region, the fountain to student ratio specified in state plumbing codes, and whether the plumbing code allowed nonplumbed water sources. Further research regarding how drinking fountain requirements in plumbing codes relate to drinking water availability in schools and other places would be useful for states and communities that wish to increase drinking water access to support healthy beverage intake among their residents.


There are several definitions of level 1 (L1) care, all refer to a group at risk of clinical deterioration on the ward . There iData were collected as part of NSCCCN's observational prevalence study in 2010. Ward surveys included acuity of illness, staffing levels and skill mix. Secondary data were obtained from the Patient Administration System. Emergency, oncology, paediatric and maternity units were excluded.P = 0.058 Fisher's exact), but this was not statistically significant. Senior nursing (Band 6) staff were part of the skill mix on only nine of 44 ward surveys.Complete datasets were obtained from 1,402 patients in 22 wards in our university hospital over two seasons. This constitutes 98.3% of inpatients from those wards. The mean ward occupancy rate was 94% (10th to 90th percentile: 85% to 100%). At least one L1 acuity criterion was scored by 898 (64%) patients, with 25% from geriatrics followed by orthopaedics (17%) and general surgery (10%). Each ward had an average of eight qualified nursing staff (range: 4 to 12) equating to an average staff:patient ratio (SPr) of 0.253. There was no correlation between ward occupancy and nursing staff , nor between prevalence of L1 criteria and staffing (corr: 0.34). The admission rate to intensive care was noted to be higher if the patients were nursed in a ward with lower than average SPr compared with higher SPr (2.7% vs. 1.2%, Better outcome with improved SPr may be unsurprising, although if proven conclusively would significantly inform workforce planning. Lack of correlation between staffing levels and occupancy or acuity is also interesting given that we know L1 criteria are associated with worse outcome.


In conclusion, immunosuppressed patients with bronchopulmonary symptoms should attentively be examined with regard to flagellated protozoa which can easily be misidentified as epithelial cells.Flagellated protozoa that cause bronchopulmonary symptoms in humans are commonly neglected. These protozoal forms which were presumed to be “flagellated protozoa” have been previously identified in immunosuppressed patients in a number of studies, but have not been certainly classified so far. Since no human cases of bronchopulmonary flagellated protozoa were reported from Turkey, we aimed to investigate these putative protozoa in immunosuppressed patients who are particularly at risk of infectious diseases. Bronchoalveolar lavage fluid samples of 110 immunosuppressed adult patients who were admitted to the Department of Chest Diseases, Hafsa Sultan Hospital of Celal Bayar University, Manisa, Turkey, were examined in terms of parasites by light microscopy. Flagellated protozoal forms were detected in nine (8.2%) of 110 cases. Metronidazole (500 mg  Cryptosporidium, Entamoeba histolytica, and Leishmania which are single-cell eukaryotes, are amongst the microorganisms that rarely cause infections in the respiratory system. Severity of these infections can vary according to the immune status, which is altered in AIDS, organ transplantation, cancer, and corticotherapy [ Lophomonas blattarum is another example of a single-cell eukaryote that occasionally appears to infect humans. Only a few articles reported that Lophomonas blattarum and other flagellated protozoa caused bronchopulmonary infections in humans [ L. blattarum by Levent Doğancı .Protozoa such as Microsporidia,otherapy . Lophomon humans –6. No hu L. blattarum, and the other flagellated protozoa in bronchial secretions, bronchial epithelial cells could easily be misidentified as flagellated protozoa [ Lophomonas blattarum is a flagellated protozoon found in order Hypermastigida and suborderLophomonadina. It is accepted as an endocommensal in the intestine of cockroaches such as Periplaneta americana and Blattella orientalis. L. blattarum is approximately 20–60 μm in length and has round to oval shape [Ribas et al. reported that, in the case of pulmonary infections in immunosuppressed patients, examining bronchial secretions including bronchoalveolar lavage fluid (BALf) would be more useful to detect certain microorganisms . It has protozoa , 9. Lophal shape .Mode of transmission of these flagellated protozoa still remains a mystery. The most frequent symptoms in humans are fever, cough, and sputum expectoration . RadioloEven though bronchoscopy is an invasive method, parasitic examination of BALf was performed in immunosuppressed patients in whom fiberoptic bronchoscopy (FOB) was indicated for other pathologies. The aim of this study was to investigate bronchopulmonary flagellated protozoa in immunosuppressed patients.BALf samples were obtained by FOB  from 110 immunosuppressed adult patients who were admitted to the Department of Chest Diseases, Celal Bayar University, Manisa, Turkey, between 2011 and 2012. BALf collection was performed by wedging the tip of the bronchoscope into the nondependent lobes, especially middle lobe of the right lung and lingula of the left lung in each patient. The BALf collected lobe was determined by the images of the lesion with the greatest radiological abnormality. About 100 mL of sterile physiologic saline warmed to the body temperature was instilled in 20 mL aliquots. Gentle manual suction was applied to retrieve the saline. BALf was collected in sterilized containers and brought to the laboratory. Apart from these, additional invasive surgery was not applied to the patients.μm in length) with granular cytoplasm and wavy, not combed flagella of different lengths without a terminal bar were considered to be flagellated protozoa  within half an hour. A drop of BALf was put on the slide and covered with a coverslip for direct wet mount examination. This preparation was used primarily to observe the movements of cilia or flagella of putative protozoan and epithelial cells. Round or oval, motile trophozoites . Second FOB was carried out in positive cases as a follow-up control after treatment. A questionnaire was also given to positive cases.Cases positive for protozoal forms were treated with metronidazole  and all patients were informed and written consents were taken.Flagellated protozoa were found in nine of 110 (8.2%) immunosuppressed patients. No flagellated protozoa were detected in BALf samples of all positive cases after treatment. In follow-up controls, it was observed that the initial pulmonary symptoms were considerably recovered in all cases. L. blattarum, which has similar morphology like other protozoal forms, has been reported in some studies [ L. blattarum and bronchopulmonary protozoal infections has recently been published [Only a few human cases have been reported in the world on bronchopulmonary infection caused by flagellated protozoa , 8. Howe studies –4, 12. Aublished .L. blattarum, arguing that the bronchial epithelial cells could easily be misidentified as flagellated protozoa, which is in agreement with our experience in our series of 110 patients. A detailed table was reported which can be very useful to distinguish protozoal forms from ciliated epithelial cells [ L. blattarum from other protozoal forms. Thus, we defined all the parasitic forms we detected as flagellated protozoa. We observed nearly 1 or 2 bronchopulmonary flagellated protozoan cells per 10 microscopic fields (×400) while numerous epithelial cells were seen in each field in direct examination of BALf samples. Moreover, epithelial cells formed clusters in most of microscopic fields, so the protozoan cells could easily be overlooked. This paper highlights the need for molecular techniques to detect their presence and to differentiate the protozoal forms in respiratory secretions. Apart from these, culture studies we performed with Trypticase-Yeast-Maltose, Cystein-Peptone-Liver-Maltose, and Novy-Nicolle-McNeal media had unfortunately failed. We think successful cultivation of these parasites will enable us to describe detailed morphological features, to improve specific molecular techniques, and to develop novel treatment choices.Ribas et al.  and Martal cells . Based en = 85) with different respiratory disorders showed a greater number of protozoal forms in the sputa of patients with AIDS (86.7%) in comparison to the other two groups. Protozoal forms were found in 34.8% and 18.8% in non-AIDS immunocompromised patients and in control group, respectively, in that study. In a Letter to the Editor which reported an AIDS case [A cytological study  in whichIn a study in which the relationship between protozoa and asthma was evaluated , data suIn our study, the cases infected with flagellated protozoa were treated with metronidazole and after the treatment a second FOB and chest radiography were performed for follow-up control. One of the common points in the literature was to use metronidazole in the treatment , 8. HoweWe conclude that immunosuppressed patients with bronchopulmonary symptoms should attentively be examined with regard to flagellated protozoa which can easily be misidentified as epithelial cells.


This correlational study investigated a new measure of environmental spatial ability  called the virtual spatial navigation assessment (VSNA). In the VSNA, participants must find a set of gems in a virtual 3D environment using a first person avatar on a computer. The VSNA runs in a web browser and automatically collects the time taken to find each gem. The time taken to collect gems in the VSNA was significantly correlated to three other spatial ability measures, math standardized test scores, and choice to be in a STEM  career. These findings support the validity of the VSNA as a measure of environmental spatial ability. Finally, self-report video game experience was also significantly correlated to the VSNA suggesting that video game may improve environmental spatial ability. Recommendations are made for how the VSNA can be used to help guide individuals toward STEM career paths and identify weaknesses that might be addressed with large scale spatial navigation training. Spatial ability has been shown to play a significant role in achievement in science, technology, engineering, and mathematics (STEM) disciplines. For instance, One way spatial ability can be improved is through playing action video games e.g., . For exaOf particular importance in understanding the malleability of spatial ability is the distinction between figural, vista, and environmental related spatial abilities . FiguralSpecific processes in environmental spatial ability may result from the accumulation of three main types of knowledge of the environment: landmark, route, and configurational knowledge . First, r = 0.61) suggesting that the cognitive processes being used in virtual simulations are similar to the ones being used in real environments  based on one’s memory of an environment may be a source of construct irrelevant variance in the assessment of environmental spatial ability  with tests of spatial knowledge that involve orienting oneself within real-life environments  le e.g., , the VSNThe VSNA will relate higher to math SAT scores than verbal SAT scores. Spatial skills correlate to math achievement  nt e.g., . TherefoThe VSNA, SOT, and MRT will relate to STEM career path and achievement after controlling for gender, verbal and math ability (via SAT scores). Spatial ability has been found to predict STEM degree attainment ((3) tainment . Thus weThe second question refers to the extent to which video game use influences environmental spatial ability (as measured by the VSNA). The question further addresses the malleability argument that video game use can impact spatial ability and specifically, environmental spatial ability. While this study focuses on correlational relationships, it is informative since it may show that even casual video game use can have a potential effect on environmental as well as vista and figural spatial ability.Despite the large body of work investigating the role of video games on spatial ability, we are aware of only three studies that have specifically investigated the relationship between video game use and environmental spatial ability . SchusteWe make the following hypothesis regarding question two:Video game use will relate to performance on all measures of spatial ability . Higher video game use will be associated with in better spatial abilities compared to less video game use.(4) 323 undergraduate students  enrolled in introductory psychology and education courses at a large southeastern state university volunteered to participate in the study for course credit.Figure 1 displays a screenshot of the easy indoor environments.The VSNA was created in Unity, a free video game development software tool. In the VSNA, a participant explores a virtual 3D environment using a first person avatar on a computer. The avatar is controlled by a single key on the keyboard and the mouse. Pressing the key moves the avatar forward and the mouse controls the direction of the avatar. Participants are instructed that the goal is to collect three gems in an environment and return to the starting position. Participants first complete a short familiarization task that requires them to collect three gems in a small room. The VSNA consists of: (a) a small indoor environment consisting of halls (easy indoor), (b) a larger indoor environment (hard indoor), (c) a small outdoor environment (easy outdoor), and (d) a larger outdoor environment (hard outdoor). In each environment three gems are strategically located in the four environments so that an optimal path can be used to collect all the gems. In each environment the participant must collect the gems twice. The first collection is the training phase and the second collection is the testing phase. search and encode information in the environment, while the testing phase is intended to measure one’s ability to retrieve and apply the encoded information. There is a 5 min time limit (per phase) in the easy indoor environment. The hard indoor and both outdoor environments each have a 10 min time limit per phase. If a person times out in a training phase, the participant skips the testing phase and goes to the next environment. The automated skip was done to keep the testing phase a recall task not a searching task. Lower score indicate higher environmental spatial ability. For ease of reading we reverse coded the VSNA scores so higher scores mean better performance.The VSNA records the time taken to complete the training and testing phases per environment . The training phase is intended to measure one’s ability to This test consists of 15 self-report items pertaining to environmental spatial ability  that are rated on a five point likert scale. Higher score indicate higher environmental spatial ability.Imagine you are looking at the tree from the position of the cat, now point to the car. The participant must draw the direction in a circle relative to an arrow in the circle that is always pointing to the 12 o’clock position. Each response is scored as a difference between the participant’s angle and the correct angle (ranges from 0° to 180°). Larger differences between a participant’s drawn angle and the correct angle indicate lower vista spatial ability. For ease of reading we reverse coded the SOT scores so higher difference scores mean greater vista spatial ability.This test consists of 12 questions requiring the participant to estimate locations of objects from different perspectives in one picture. In each item the participant is told to imagine looking at one object from a particular location in the picture and then point to a second location. An example item is as follows: In this test, participants view a three-dimensional target figure and four test figures. Their task is to determine which of the test figures are rotations of the target figure. The MRT has two correct answers for each of the 10 items. The total score is based on the total number of items where both correct objects are found. Higher score indicate higher figural spatial ability.Participants answered one question about general video game use: How often do you play video games? 1 = not at all, 2 = about once a month, 3 = a few times a month, 4 = a few times a week, 5 = everyday, but for less than 1 h, 6 = every day for 1–3 h, 7 = every day for more than 3 h . AdditioThe study was conducted online in a web browser without supervision. Participants first reported their GPA, SAT scores, academic major, and completed the SBSOD scale. Then they completed the VSNA, the SOT, and the MRT. Finally, they completed some questions about video game use and usability of the VSNA. No tests were counterbalanced since we wanted to see how participants performed on the VSNA without the influence of fatigue from other spatial ability tests.Table 1 displays the means and standard deviations of the SBSOD, times across the eight phases of the VSNA, the SOT, and MRT (listed in the order they were presented). Due to the difficult nature of the VSNA hard environments, and the study being unproctored, not all participants completed all tests. In some cases a participant timed-out of a training environment which results in the participant skipping its corresponding testing phase (as described in the VSNA measures section). In order to maximize power we still included participants in analysis who completed the training phase for each environment.r = 0.61), we took the average score across training and testing. Easy and hard times were also highly related (r = 0.56) so we took the average score across easy and hard times to yield an indoor and outdoor VSNA score. While the correlation between indoor and outdoor environments was also high (r = 0.53), we report results for them separately since the sample size differs between the indoor and outdoor environments. Additionally, combining the time data across the indoor and outdoor environments could give an added advantage to participants who did not complete the outdoor task .Reliability was good for the SBSOD (α = 0.89), MRT (α = 0.76), and SOT (α = 0.87). Based on the high correlation between VSNA testing and training times (n = 36) were excluded from the STEM major variable. Table 2 displays the correlations between STEM career path , gender , SAT math scores, MRT, SOT, and the indoor and outdoor VSNA scores . GPA was omitted from Table 2 since it did not relate to any spatial ability measures.We recoded students’ self-reported major into two categories: STEM related and non-STEM related. Examples of STEM related majors include: biology, engineering, computer science, and chemistry. Examples of non-STEM related majors include: English, education, business, communication, and history. Non-majors (r = 0.37) relative to the MRT (r = 0.24) and the SOT (r = 0.18). The r = 0.37) and SOT (r = 0.18) is significant . The difference between SBSOD (r = 0.37) and MRT (r = 0.24) is significant . The VSNA indoor and outdoor times both account for unique variance in the SBSOD after controlling for MRT and SOT scores .Regarding hypothesis one  both the indoor and outdoor VSNA scores significantly relate to the SBSOD, MRT, and the SOT. However, only the indoor VSNA scores appear to support hypothesis one: indoor VSNA scores are more highly correlated to the SBSOD , all spatial ability measures related to SAT math scores. No spatial ability measures related to GPA or verbal SAT.p < 0.01; R2 change = 0.04, F = 10.13, p < 0.05). The same analysis was conducted entering VSNA outdoor scores last  but the R2 change was not significant. GPA did not relate to any spatial ability measures for the STEM majors (n = 119).Regarding hypothesis three , gender, SAT math scores, SBSOD, and both indoor and outdoor VSNA scores significantly relate to STEM majors. A hierarchical regression was run to predict STEM major. Predictors were entered in the following order: gender, math SAT scores, SBSOD scores, and finally VSNA indoor scores. Only VSNA indoor was a significant predictor of STEM interest after controlling for all other predictors  and VSNA indoor scores and .Regarding hypothesis four , video game use significantly relates to the four spatial ability measures. However, after controlling for gender and video game similarity (for VSNA only), video game use only relates to SOT  was partially confirmed. We found that indoor VSNA scores had moderately highly correlations to SBSOD scores than to MRT and SOT scores. Both the VSNA indoor and outdoor scores accounted for unique variance in the SBSOD after controlling for MRT and SOT scores. These findings partially supports the construct validity of the VSNA as a measure of environmental spatial ability. We did not find evidence of construct validity for the outdoor VSNA scores . This finding may be due to the outdoor environments always being after the indoor environments which could cause fatigue effects on the outdoor environments. Finally, method effects  and well known psychometric issues related to self-report measures  could be a reason why the correlation was not higher between the SBSOD and the VSNA.Hypothesis two  was confirmed. We found that the VSNA, MRT, and SOT scores were all significantly related to math SAT scores and not verbal SAT scores. This is consistent with other research e.g.,  that hasHypothesis three  was partially supported. The VSNA indoor scores significantly correlated to being a STEM career path after controlling for gender, math SAT scores, and SBSOD scores . Thus we established criterion related validity of the VSNA. This finding extends the work by Hypothesis four  was partially supported. Video game use was significantly correlated with the SOT and the indoor VSNA after controlling for gender. Importantly, the VSNA does not just assess one’s ability to play video games–video game use significantly relates to the VSNA after controlling for VSNA-video game similarity. The relation between video game use and the VSNA might be underestimated considering we only asked a broad question about video game use. Future work should consider using more detailed questions regarding video game use to further identify if specific video game use  relates more strongly to the VSNA.in real environments  but not to pointing performance after navigating through real environments.A case can also be made that the VSNA-video game similarity question might not be sufficient to measure how similar the VSNA is to video games. For example, a particular video game player might see lots of differences between the VSNA and video games in general , while another video game player might see lots of similarities . Future work should consider more detailed questions regarding the similarity between the VSNA and video games. However, the VSNA requires little motor control beyond skills learned by normal computer use (single button press with one hand and mouse control with the other hand). In this regard, the VSNA can be seen as a transfer task of environmental spatial ability independent from other video game play heuristics . These results are consistent with experimental evidence that video game use can improve spatial ability e.g., . Thus exFinally, the positive relation between video game use and environmental spatial ability also shows what lifestyle factors might indirectly affect interest in STEM . While we did not find that video game use directly relates to STEM interest, video game use may indirectly affect interest in STEM by positively affecting environmental spatial ability and math ability.Consistent with other work on spatial abilities e.g., , we founLooking forward, the VSNA could potentially be used for large scale assessment since it is scalable  and quick to administer (as short as 10 min). This is important due to the growing number of studies suggesting the need to assess spatial ability in our education system e.g., . There aThis study cannot rule out the selection hypothesis that people with high environmental spatial ability may enjoy playing video games more than people with low environmental spatial ability. Future work should focus on experimental research investigating how using 3D simulations or video games can improve performance in the environmental spatial ability. Another limitation in this study was students completed all tests online without proctor supervisions. Results might have been more robust if participants were directed to stay on task throughout the session.Another limitation of this study was we were not able to investigate the latent factorial structure of the VSNA. Given the limited time we had to run reach participant we could only investigate two levels of difficulty (easy vs. hard) in two distinct environments (indoor vs. outdoor). Future work should investigate creating “forms” of the VSNA that contain multiple isomorphic environments of similar difficulty . These forms can be compared to other forms that contain other features of the VSNA . This design allows for confirmatory factor analysis and structural equation modeling. Additionally, counterbalancing and time spacing between forms should be implemented to control for any fatigue effects that may be occurring as a function of extended VSNA testing.Finally, virtual environments do not provide any information to body-based senses  and thus may afford less detailed representations than real world environments . HoweverThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Thickness changes of corneal sub-layers after phacoemulsification were investigated by spectral domain ultra-high resolution optical coherence tomography (UHR-OCT). The corneas (n = 26) of 26 age-related cataract surgery patients were studied. UHR-OCT was used to evaluate the thickness of Descemet’s Endothelium Complex (DEC), stroma, Bowman’s layer, epithelium, and full cornea at the center (CCT) before, one day after, and one week after surgery. Non-contact specular microscopy measured CCT, endothelial cell density, and morphology.The DEC, stroma, Bowman’s layer, and epithelium were visualized by UHR-OCT. Before surgery, the DEC in all cases appeared as a translucent space between two smooth opaque lines. One day after surgery, the posterior corneal surfaces in half of the eyes were wavy and irregular. Compared to the baseline, one day after surgery the thickness increases of the DEC, stroma, and CCT were 4.3 ± 2.6 µm, 25.5 ± 24.9 µm, and 32.1 ± 26.6 µm, respectively (P < 0.001). The morphology of the DEC and the CCT recovered to baseline one week after surgery (P > 0.05), but endothelial cell density was 8.7% less than at baseline. There were no significant changes in Bowman’s layer and epithelium after the operation. The pre-operative DEC thickness was positively correlated with the decreased endothelial cell density at 1 day after surgery .The DEC showed edematous thickening and different degrees of morphological changes after phacoemulsification. The DEC deformation and corneal edema recovered by one week after surgery, which indicated recovery of endothelial function. UHR-OCT is a useful tool to evaluate function of the DEC after phacoemulsification. Pre-operative DEC thickness may indicate the integrity of the endothelium and could be used for predicting endothelial cell loss after phacoemulsification.  The evolution of phacoemulsification surgery has resulted in a trend towards improved visual acuity with optimal safety and minimum invasiveness . HoweverSeveral methods have been used to assess endothelial function post-operatively: specular microscopy and in vivo confocal microscopy for endothelial morphology, fluorophotometric measurement of corneal barrier functions, and pachymetry for central corneal thickness (CCT) -9. HowevAll patients were candidates for phacoemulsification surgery and intraocular lens implantation at the Eye Hospital, Wenzhou Medical College, Wenzhou, Zhejiang, China. The study was approved by the Wenzhou Medical College review board, and written informed consent was obtained from each patient. All patients were treated in accordance with the tenets of the Declaration of Helsinki. Age-related cataract was diagnosed on slit-lamp examination based on the opacity of the crystalline lens by the same examiner (ZC). For each patient, the cataract hardness was between II and IV according to the Emery and Little nuclear hardness classification . ExclusiAll subjects were tested pre-operatively as well as one day and one week after surgery. The cataract was diagnosed bilaterally for each subject, but only one eye of each subject was randomly selected for study. The measurements were executed between 10:00 am and 5:00 pm. During each visit, non-contact UHR-OCT, specular microscopy, and tonometry were performed in the selected eye of each subject by the same veteran examiner (ZC). The surgical procedure was performed by the same veteran surgeon (YZ). An Infiniti phacoemulsificator  was used. The surgical settings were shown in 2. Among the five patients for whom Duovisc was used, the lens nucleus of four subjects was graded III, and the nucleus of the other subject was graded IV. The mean phacoemulsification time in the Duovisc group was 58.8 sec, and 43.0 sec in the Iviz group. The bottle height was 100.0 cm. The mean phacoemulsification energy was 22.9 ± 8.9%. The mean size of corneal incision was 2.8 ± 0.4 mm. For seven patients, the corneal incision size was 2.2 mm, and for the other 19 patients it was 3.0 mm. No intracameral antibiotics or intracameral anesthesia was used. The surgical procedure was free of complications for all patients. A topical combination of steroids and antibiotics was given three times daily for 4 weeks as the post-operative treatment.Duovisc was used when the lens nucleus was hard, or corneal endothelial cell density was less than 2,000 cells/mmTo detect the sub-layers of the cornea, a custom-built high speed, spectral domain UHR-OCT instrument was used for this study. It was similar to the device used in previously published studies ,16. A suDuring imaging, the subjects were asked to sit in front of the UHR-OCT instrument and look straight ahead to an external central target. To image the structural characteristics and calculate the thickness of all corneal layers including the DEC layer, a 6.1 mm horizontal scan was taken when the light crossed the corneal apex. Custom software was used to process the raw data as described in a previous study . The refThe repeatability of measuring the thickness of the epithelium and Bowman’s layer has been validated by our previous studies using the same method ,19, and A non-contact specular microscope  with an autofocus was used to determine the CCT, the endothelial cell density, and cell shape . After tIntraocular pressure (IOP) was evaluated by a non-contact tonometer . No anesthesia was used during the examination. Three readings were taken and averaged.The Statistical Package for the Social Sciences  was used for data analysis. Data were presented as means ± standard deviations. Repeated measurement analysis of variance was used for overall statistical testing. A separate analysis was carried out for each layer of the cornea. Fisher’s Least Significant Difference (LSD) post hoc tests were used to determine if there were differences in thickness of total cornea and corneal sub-layers among all visits. Paired samples t-test was used to compare CCT between instruments at each visit. Changes in endothelial cell density by visit were tested using Wilcoxon test. Spearman correlations among different parameters were determined. P-values < 0.05 were considered statistically significant. Using a similar UHR-OCT instrument, Shousha et al.  found thThe study included 26 eyes of 26 age-related cataract patients . Pre-operatively, the DEC, stroma, Bowman’s layer, and epithelium were visualized in UHR-OCT images as bands separated by smooth opaque lines . Prior tThe thickness of the central DEC before phacoemulsification surgery was 12.7 ± 1.8 μm . One day2 . The visual acuity at 1 day post-operatively in the patients who showed deformation of the endothelium and who did not was 4.81 ± 0.25, and 4.89 ± 0.18, respectively (P = 0.060). The pre-operative IOP was 12.1 ± 2.3 mmHg, 12.8 ± 3.8 mmHg at 1 day after surgery, and 10.9 ± 2.8 mmHg after one week . The pre-operative DEC thickness was positively correlated with the decrease of endothelial cell density between pre-operative and 1 day post-operative values , corneal decompensation, bullous keratopathy, and loss of vision occurs [Similar to other studies -32, the n occurs . AlthougEstablishing the relationship between the thickness and en-face morphology of the DEC may help to better understand the corneal responses to surgical procedures that can cause subclinical wounding during phacoemulsification. The pre-operative DEC thickness was positively correlated with the decrease of endothelial cell density at 1 day after surgery. However, the relationship between endothelial cell density imaged by confocal microscopy at baseline and endothelial cell loss one day after surgery was not evident in the present study. Our data showed that morphological and thickness analysis of the DEC obtained by UHR-OCT provided a more precise indicator of endothelial cell damage than specular microscopy alone. The cross-sectional thickness of the DEC pre-operatively imaged by UHR-OCT may indicate the integrity of the endothelium. In turn, this information may be used for predicting the endothelial cell loss after phacoemulsification. For the patients who did not develop wave-like morphological changes, the DEC increased after surgery, but stromal and total corneal thicknesses did not change. This indicates that the DEC may be a more sensitive parameter than other thickness parameters. It may be not feasible for everyone to use UHR-OCT to image the DEC due to the high cost and limited availability of commercial UHR-OCT instruments. Measuring stromal or total corneal thickness may be valuable in roughly determining corneal response to surgery. Considering the high resolution and wide scan width, UHR-OCT may add an alternative modality for studying the DEC thickness and morphology; however, UHR-OCT may not replace specular microscopy for imaging the endothelial cells. The values for CCT estimated by UHR-OCT and specular microscopy were similar to one another. The thickness of epithelium in the present study, 47.4 ± 3.6 µm, is in agreement with previously reported values . HoweverThere were some limitations in this study. The follow-up time was only one week after surgery. Although we found that the corneal sub-layer thicknesses recovered post-operatively, other parameters such as corneal endothelial cell density did not return to baseline. It is possible that a longer follow-up period would have shown that the endothelial cell density tended to recover or possibly continued to decrease . A seconIn summary, one day after phacoemulsification in age-related cataract patients, the cornea became thickened principally due to stromal edema and to a lesser extent DEC edema. The DEC displayed different types of morphological changes. The complex sub-layer deformations and corneal edema recovered by one week after surgery. This indicated that endothelial cells, though less dense than before surgery, were able to recover the functional state and restore the normal thickness of cornea. The thicknesses of the epithelium and Bowman’s layer did not change during the early post-operative period. The cross-sectional thickness of the DEC pre-operatively imaged by UHR-OCT may indicate the integrity of the endothelium, which, in turn, may be used for predicting endothelial cell loss after phacoemulsification. Considering the high resolution and wide scan width, UHR-OCT may add an alternative modality for studying the DEC thickness and morphology, although UHR-OCT cannot replace specular microscopy in imaging the endothelial cells.


I received Iranian Journal of Parasitology (Volume 6 (4), Oct-Dec 2011). I have seen an article in pages 51-58 titled “Molecular and Seroepidemiological Survey of Visceral Leishmaniasis among Humans and Domestic Dogs in Mazandaran Province, North of Iran ”.I think this title needs to be revised, because this study was done in two limited districts of the central zone of Mazandaran (Semeskandeh near Sari City (3-5 kilometer) and Kiakola district near Qahmashare City. Therefore, this study can not be considered as a study for the entire Mazandaran Province . The authors must have written the title according to the study area, because it is important for the future studies. You know, Mazandaran has a different climate and ecological conditions which effects on the species and the distribution or transmission of parasitic agents in different areas. In addition, I think in this article the previous studies in this province have not been considered properly.SincerelySH Gholami (PhD)Assistant ProfessorDepartment of Parasitology & Mycology,Faculty of Medicine, Mazandaran University of Medical Science, IranEmail: sgholami@mazums.ac.ir


In this study, we investigate a variable-resolution approach to video compression based on Conditional Random Field and statistical conditional sampling in order to further improve compression rate while maintaining high-quality video. In the proposed approach, representative key-frames within a video shot are identified and stored at full resolution. The remaining frames within the video shot are stored and compressed at a reduced resolution. At the decompression stage, a region-based dictionary is constructed from the key-frames and used to restore the reduced resolution frames to the original resolution via statistical conditional sampling. The sampling approach is based on the conditional probability of the CRF modeling by use of the constructed dictionary. Experimental results show that the proposed variable-resolution approach via statistical conditional sampling has potential for improving compression rates when compared to compressing the video at full resolution, while achieving higher video quality when compared to compressing the video at reduced resolution. Over the last two decades, digital video compression has become one of the fastest growing areas of research and development around the world, where the underlying goal is to take digital video content and encode it in a form that minimizes the requirements for digital storage and/or transmission. There is a continually increasing demand for better digital video compression technologies, particularly since digital video has become an integral part of our daily lives, with mass digital video consumption in a wide range of application scenarios such as digital TV broadcast  Variable-resolution compression stage, and ii) Decompression stage. In the variable-resolution compression stage, the identified representative key-frames are compressed at full resolution while the rest of the frames are compressed at a lower resolution. Secondly, in the decompression stage, all of the frames within the video content are decompressed at their respective resolutions, a full resolution region-based dictionary is constructed from the representative key-frames and then the low resolution frames are restored to the original resolution via statistical conditional sampling based on the dictionary and conditional probability of CRF. An flowchart summarizing the proposed approach is shown in At the first step in compression stage, representative key-frames are identified and extracted within a video shot. To achieve this goal, we wish to first determine an appropriate metric for quantifying the similarity between every frame pair within the shot. Given the importance of structures of objects within a scene, we chose to employ the well-known SSIM metric proposed by Wang et al. video statistical features are usually highly spatially/temporally nonstationary,video distortions may also be space/time variant,at one time instance and at a typical viewing distance, only a local area in the image can be perceived with high resolution by the human observer, anda localized quality measurement can provide a space-time varying quality map of the image, which delivers more information about the quality degradation of the image and may be useful in some applications.Having considered the above properties, the SSIM metric can be defined asTo utilize the SSIM metric for assessing video frame similarity so that we can identify representative keyframes, an SSIM matrix  compressing the entire video sequences at full resolution using H.264 The potential use of statistical conditional sampling for variable-resolution video compression to further improve compression rate while maintaining high quality video was studied. In the proposed approach, the representative key-frames were first identified within a video shot. The representative key-frames were compressed at the original resolution while the remaining frames within the video shot are compressed at a reduced resolution. Upon decompression, the reduced resolution frames are restored to the original resolution via statistical conditional sampling based on the original resolution representative keyframes. Experimental results demonstrate the potential of the proposed approach for improving compression rates when compared to compressing the video at full resolution, while achieving higher video quality when compared to compressing the video at reduced resolution. Future work involves exploring improved key-frame identification methods as well as improved frame restoration approaches.


Autologous stem cell transplantation (ASCT) is the gold standard therapy for suitable multiple myeloma (MM) patients after induction with high dose therapy. To date, the evidence of a reliable marker of prognosis in these cases remains scarce. Our aim was to evaluate appearance of unrelated atypical serum immunofixation patterns (ASIPs) as a marker of prognosis in MM patients submitted to ASCT. We retrospectively analysed data from 65 patients. Interestingly, we observed that presence of ASIPs was associated with longer progression-free survival and longer overall survival. Our results suggested that presence of ASIPs could be a novel marker of good prognosis in MM patients submitted to ASCT. Multiple myeloma (MM) is a plasma cell neoplasia characterized by abnormal production of monoclonal immunoglobulin detectable in serum and/or urine . Howeverp value of 0.05 was considered significant.Our aim was to evaluate the appearance of ASIPs on serum immunofixation (IEF) as a prognosis marker in MM. Patients with MM, less than 65 years old and without comorbidities that underwent ASCT were included. Staging of disease followed the Salmon-Durie and International Staging System (ISS) and number of ASCT per patient was recorded. Immunotypes were determined by IEF (HYDRASYS® agarose gel electrophoresis). ASIPs was defined as the appearance of new mono or oligoclonal immunoglobulin protein bands (with either light or heavy chain components). Patients were stratified according to the presence or absence of ASIPs. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Mayer method and comparisons between groups were made using log-rank test. Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables were used. Analysis of Covariance (ANCOVA) was performed. A p = 0.012) and in death rate .Between January 2000 and June 2009, 65 patients with MM submitted to ASCT were studied Table . Accordip = 0.019). Figure p = 0.014). As compared to the absence of ASIPs, the presence of this component in serum IEF was also associated with a hazard ratio for death of 0.33 . Figure p = 0.002) for patients with presence of ASIPs. When adjusted for age, PFS and OS remained significantly different between the two groups . These results points toward the hypothesis that presence of ASIPs may be a protector feature in MM patients submitted to ASCT. This is in concordance with recent results from Wadhera and colleagues [Oligoclonality, as compared to the absence of ASIPs, was associated with a hazard ratio for relapse of 0.49 (95 % CI, 0.26-0.89; lleagues .We concluded that presence of unrelated atypical serum immunofixation patterns could be a possible laboratory marker of good prognosis in MM patients after ACST. Further studies are needed to confirm our results.MM, Multiple myeloma; ASCT, Autologous stem cell transplantation; IEF, serum immunofixation; ASIPs, atypical serum immunofixation patterns; ISS, International Staging System; OS, overall survival, PFS: Progression-free survival.The authors declare that they have no competing interests.CG and RR designed the study; CG, RR and RB interpreted data; GC and RR wrote the manuscript; RB and FT reviewed diagnoses; RR and NC performed the statistical analysis; RB and FT collected data. All authors have read and approved the final manuscript.


Alcohol use is increasing among women in Africa, and comparable information about women's current alcohol use is needed to inform national and international health policies relevant to the entire population. This study aimed to provide a comparative description of alcohol use among women across 20 African countries.Data were collected as part of the WHO World Health Survey using standardized questionnaires. In total, 40,739 adult women were included in the present study. Alcohol measures included lifetime abstinence, current use (≥1 drink in previous week), heavy drinking (15+ drinks in the previous week) and risky single-occasion drinking (5+ drinks on at least one day in the previous week). Country-specific descriptives of alcohol use were calculated, and K-means clustering was performed to identify countries with similar characteristics. Multiple logistic regression models were fitted for each country to identify factors associated with drinking status.A total of 33,841 (81%) African women reported lifetime abstinence. Current use ranged from 1% in Malawi to 30% in Burkina Faso. Among current drinkers, heavy drinking varied between 4% in Ghana to 41% in Chad, and risky single-occasion drinking ranged from <1% in Mauritius to 58% in Chad. Increasing age was associated with increased odds of being a current drinker in about half of the countries.A variety of drinking patterns are present among African women with lifetime abstention the most common. Countries with hazardous consumption patterns require serious attention to mitigate alcohol-related harm. Some similarities in factors related to alcohol use can be identified between different African countries, although these are limited and highlight the contextual diversity of female drinking in Africa. Alcohol use is an important factor in any woman's health risk profile. Harmful patterns of alcohol consumption are strongly associated with increased morbidity and mortality . AlcoholAlcohol use among women in Africa has traditionally been quite low, and high rates of lifetime abstention persist in many African countries . HoweverAfrican countries are categorized as low to middle income, and as such are often limited alcohol-policy environments . As obseA recent study using data from the WHO's World Health Survey observed diverse patterns of drinking among 20 African countries, supporting the contention there is a variety of national drinking habits across the African continent . This stThe WHO's World Health Survey provided data on alcohol use and sociodemographics among women in 20 African countries . Using tThe data used for this study is publicly available from the WHO. Data were collected as part of the WHO World Health Survey (WHS) between 2002 and 2004 in 20 African countries . HousehoIn total 77,165 adults aged 18 years and older were included, and of these, 40,739 (53%) were women. Response rates were reported at both the household and individual level and varied between 54 and 98% at the household level (median = 90%), and 85 and 99% at the individual level (median = 98%) .The WHS used identical questionnaires for the face-to-face interviews in all 20 countries. Individual level data included sociodemographic variables such as marital status, education and employment. WHS protocols and procedures were approved by the ethics committees in each participating country and informed consent was obtained from all participants. The instruments and sampling designs are described in further detail elsewhere ,24.The question "have you ever consumed a drink that contains alcohol?" was used to identify lifetime abstainers. If the respondent indicated positively, they were asked "how many standard drinks were consumed each day in the past 7 days". From this, we constructed three variables related to drinking: 'current drinkers' were defined as any respondent who consumed at least 1 standard drink in the previous 7 days; 'heavy drinkers' were defined as those who had consumed a total of 15 or more standard drinks during the last 7 days; and 'risky single-occasion drinkers' were defined as those who consumed at least 5 or more standard drinks of alcohol on at least one day of the previous week. Note these three variables are not mutually exclusive. A showcard with pictures was used to illustrate what was meant by a "standard drink", and defined by WHS as containing between 8-13 g of ethanol depending on the country.All data were weighted, with post-stratification adjustments for age and gender using the UN population estimates as the reference population. Data were stratified by gender, and descriptive statistics presented as frequencies (%) or means (SD). Prevalences for the 'heavy drinker' and 'risky single-occasion drinker' variables are presented out of the total 'current drinker' group, unless otherwise specified. All the rates presented are weighted proportions.In order to explore whether the 20 countries could be grouped into clusters based on similarities in percentages of the three drinking variables, i.e. 'lifetime abstainers', 'heavy drinkers' and 'risky single-occasion drinkers', we performed K-means clustering, averaging over 25 runs .breakpoint, where below and above this breakpoint age has different effects on the dependent variable. For the 7 countries where age showed a linear relation to the dependent variable we thus fitted standard multiple logistic regression analyses, whereas for the 7 countries where age showed a piecewise linear relationship to the dependent variable we fitted piecewise linear logistic regression models including estimates of the accompanying breakpoint [In order to assess possible predictors of the three constructed dependent variables 'current drinking', 'heavy drinking' and 'risky single-occasion drinking', we fitted separate multiple logistic regression models for each of the 14 countries with more than 30 current drinkers. Included explanatory variables in the regression analyses were age, any education or not, currently married or cohabitating, working for pay and rural setting. In order to assess the validity of the linearity assumption in Generalized Linear Models (GLM), e.g. logistic regression, we first fitted Generalized Additive Models (GAM). GAM is a natural extension of GLM allowing for all types of functional relationships between the dependent and the independent variables . By visueakpoint .Data analysis was performed in STATA 9.0 and R 2.9.0 ,30.In total 33,841 (81%) of the African women from the 20 countries were lifetime abstainers, with rates ranging from 56% in Mauritius to 99% in Comoros .There were no consistent patterns in the significance, magnitude or direction of the covariates within the country clusters generated by the K-means clustering.Our findings show widespread lifetime abstention from alcohol use among women in 20 African countries, limited though existing heavy and risky single-occasion drinking, and no firm geographic distribution of drinking patterns across the countries examined. Among currently drinking women our findings show moderate alcohol consumption is the most common pattern, and being a risky single-occasion drinker is more common than being a heavy drinker. The results further indicate drinking increases with age in several countries, where in some countries it clearly stabilizes or declines after mid-life.The predominance of lifetime abstention from alcohol support female drinking is not a common or accepted part of African culture, likely due to religion, cultural tradition and gender roles . This "aRisky single-occasion drinking as the more common pattern of harmful use highlights the need for evidence-based, cost-effective interventions to avoid the development of alcohol related harm in countries where hazardous drinking patterns are observed. Indeed, there have already been calls from the WHO for Africa to address the harmful use of alcohol, and concerns from South Africa and Uganda about hazardous drinking habits among their female citizens -38.The clusters of countries classified with "moderate consumption", "harmful consumption" and "hazardous consumption", with Chad in a position on its own, provide further evidence different types of drinking behaviors are present among female drinkers in Africa and a diversity of drinking patterns is common across the African continent. While there may be similar rates of a single drinking pattern between clusters, rates of the other drinking measures may be quite different, and these differences would have implications for differences in national and regional alcohol policies and interventions. The countries with the highest lifetime abstention rates, which were excluded from the cluster analysis, are located in the northern part of Africa and are predominantly Muslim. These results are consistent with other studies and the Islamic doctrine ,21. HoweSociodemographic factors associated with current drinking varied across the 14 countries analysed, further reflecting the contextual diversity of alcohol use among African women. Older age was significantly associated with current drinking in 8 countries, potentially reflecting higher levels of independence and authority conferred by older age. The significant, non-linear relationship between age and current drinking observed in 5 countries is consistent with the idea of changes in drinking behavior over the lifespan, where drinking increases as age increases and then stabilizes or decreases around mid-life. This dynamic association indicates the opportunity for prevention interventions among younger age groups.any education in Africa likely represent a different demographic than those receiving any or higher education in a Western context.Having any education reduced the likelihood of current drinking in four of the five countries for which it was statistically significant save Chad. This finding is inconsistent with studies from Europe that observe an association between higher levels of education and drinking among women ,39. HoweWorking for pay was significantly associated with an increase in current drinking in Mauritius, Chad and Ghana. Not being married or cohabitating increased the likelihood of current drinking for four of the five countries for which it was statistically significant. Having one's own disposable income and being single have been identified as factors in women's alcohol consumption in resource rich and resource poor settings, and these factors may become more common and pertinent with economic development .The lack of consistent, significant associations between sociodemographic factors across all the countries and within the country clusters emphasizes the importance of local, tailored alcohol assessments in each country to ensure relevance and utility.The estimates of being a current drinker, risky single-occasion drinker and heavy drinker are likely underestimates of the true value. Stigma, religious beliefs, social norms and gender roles may contribute to the underreporting of alcohol use . ConversThe current drinker, heavy drinker and risky single-occasion drinker measures were based on a 1-week recall which may increase the precision of the amount of drinks consumed but compromise the accuracy of the measurement of women who are true "current drinkers", "heavy drinkers " or " risky single-occasion drinkers", as a 7-day recall may not necessarily reflect typical drinking behavior. Moreover, this sample contained no data on women who reported ever having a drink but no consumption in the last week, excluding a group of potential "current" drinkers, or heavy or risky-single occasion drinkers who did not drink in the previous week. Finally, no personal income variable was available in this dataset, and as noted, income is an important factor to consider in women's drinking behavior and should be purposefully included in future studies. Indeed, any variables measuring context-specific aspects of African women's use of alcohol would be useful.This paper nonetheless has important value as it covers more than a third of African countries and contributes important knowledge for describing the drinking behavior of women in Africa, and can serve as a baseline against which to measure drinking patterns in the future.A variety of drinking patterns are present among African women with lifetime abstention being the most common. The identification of countries with hazardous consumption patterns demands immediate and serious attention to avoid and mitigate alcohol-related harm. Some similarities in factors related to alcohol use can be identified between different African countries, although these are limited and diversity prevails. Further investigations are required to understand the country-specific context of female drinking in Africa and to tailor national alcohol policies.The authors declare that they have no competing interests.PM, TC and NN contributed to the design of the study. NN contributed to data collection and data management. PM led the writing and carried out statistical analysis. JR contributed to the statistical design and analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/160/prepub