Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
diabetes mellitus may predispose individuals to invasive fungal infections ( ifi ) probably
 related to impaired functions of neutrophils , macrophages , cellular and humoral immunity ,
 and iron metabolism ( 1 , 2 ) . children with type 1 diabetes ( t1d ) who present with ketoacidosis have
 increased susceptibility to infections partly due to the acidic environment that is ideal
 for certain pathogens including invasive fungi ( 1 ,
 3 ) .
majority of the ifis in children with poorly
 controlled t1d and ketoacidosis are caused by zygomycoses and are invariably fatal without
 aggressive management ( 4 ) .
the key to good outcome is
 fast and accurate diagnosis which is usually difficult to establish due to non - specific
 clinical symptoms and signs and the need for invasive diagnostic procedures for confirmation
 of ifi ( 4 , 5 ) .

the treatment is often challenging as it involves extensive surgical debridement of involved
 tissues in addition to antifungal drugs ( 4 ) .
the
 outcome is generally poor in resource constrained setups like ours but is gradually showing
 improvements ( 6 , 7 ) .
the data on outcome of ifis in children with t1d is scarce and is almost
 confined to invasive zygomycosis ( 4 ) . with an aim to
 determine the clinical spectrum and final outcome of children diagnosed with t1d and ifi
 over the last decade at our hospital , we performed a retrospective review of their medical
 records .
the analysis of hospital data of patients with t1d diagnosed to have a confirmed ifi was
 conducted at advanced pediatrics center of our institute which is a tertiary care referral
 center located in northwest india and included the period from march , 2004 to february ,
 2014 .
all patients were diagnosed as t1d according to the international society for
 pediatric and adolescent diabetes ( ispad ) criteria published in 2000 and revised in 2009
 ( 8 , 9 ) .
the
 diagnosis of associated fungal infection was based on microbiological and/or
 histopatholgical examination of tissue specimens .
data related to the basic demographic
 profile , age at the time of diagnosis , mode of initial presentation like diabetic
 ketoacidosis ( dka ) , imaging details , treatment modalities , duration of hospitalization and
 the final outcome were noted .
ten patients ( 6 girls and 4 boys ) amongst 524 children with t1d on follow up in pediatric
 diabetes clinic were treated for various ifis during the study period .
the mean ( sd ) age of
 presentation was 9.1 ( 3.4 ) yrs ( range 312 yrs ) .
the predisposing factors included poor adherence to insulin
 therapy resulting in poor metabolic control ( mean hba1c 9.3  1.2% ) and presence of acidosis
 in 9 patients and malnourished state in all ( mean bmi 12.6  1.2 kg / m ) .
nine patients presented with dka . the commonest presenting
 feature related to fungal infection with suspected rhinocerebral involvement was facial
 and/or orbital swelling in 5 patients , followed by serosanguineous nasal discharge and
 ophthalamoplegia .
the most common site of fungal
 infection was nasal cavity and paranasal sinuses seen in 6 patients ; 5 of these were due to
 mucormycosis while 1 had aspergillus flavus .
sinusitis involved ethmoid sinus in 5 patients
 and maxillary and frontal sinuses in 4 patients each ( table 1table 1clinical and
 laboratory profiles , treatment modalities and outcome of the study
 cohort ) .
lung involvement was seen in 5 patients ; 2 of these
 had pleural and thymic involvement in addition .
all patients
 showed neutrophilic leucocytosis with mean leukocyte count of 12.3  10/l .

radiological investigations included contrast enhanced computed tomography ( cect ) scans of
 suspected involved sites in all patients .
1.a : soft
 tissue opacities in frontal and ethmoid sinuses with blocked osteomeatal complex .
b :
 opacification of right maxillary sinus . ) ; 2 of these had orbital extension .

2.a & b : cect chest
 showing cavitatory pneumonia on right side . ) ; 1 patient , described elsewhere , showed
 empyema in addition ( 10 ) .
another patient had
 necrotic thick walled abscess in the thymus with consolidation of apical segment of right
 upper lobe and small subpleural nodular lesions in the right lower lobe ( 11 ) .
a : soft
 tissue opacities in frontal and ethmoid sinuses with blocked osteomeatal complex .
confirmation of diagnosis by direct microscopy of specimen ( smear / aspirate ) was made in 1
 patient , by histopathological examination in 5 patients and by both techniques in 4
 patients .
culture on sabouraud dextrose agar grew rhizopus microsporum ( rhizopodiformis ) in
 1 patient .
the most common yield was from smear or histopathological examination of tissues
 obtained at the time of surgical debridement of paranasal sinuses . in 2 patients who had
 serosanguineous nasal discharge
the
 identified etiological fungi belonged to the order mucorales in 9 cases ( 1 further
 identified as rhizopus microsporum ) and aspergillus flavus in 1 patient .
the mean time from
 presentation to diagnosis was 5.8  4.7 days ( range 114 days ) .
all patients were treated with either intravenous amphotericin b ( conventional or
 liposomal ) or voriconazole for a targeted duration of 46 weeks .
surgical intervention was
 done in 8 patients and included debridement of paranasal sinuses by either endoscopy or
 external approach in 5 , excision of brain abscesses in 1 , resection of affected lung areas
 in 2 and excision of thymic abscess in 1 patient .
mean duration of hospital stay was 41.7
  27.2 days ( range 290 days ) .
two out of 10 patients died ; 1 with pulmonary mucormycosis
 suffered massive hemoptysis on day 14 of hospitalization while the other with disseminated
 aspergillosis died of a large bout of hematemesis and showed an intestinal perforation on
 autopsy .
all survived children have remained well over a mean duration of 4.96  3.3 yrs
 ( range 9 mo9 yrs ) in follow up except 1 who continues to show mild restrictive pattern on
 pulmonary function tests .
invasive mycoses are uncommon but often lethal infections that disproportionately affect
 t1d patients with poor metabolic control ( 2 , 3 ) .
poor adherence to insulin therapy , malnourished state
 and episodes of ketoacidosis particularly predispose children with t1d to develop ifis
 ( 2 , 3 , 11 , 12 ) .
majority
 of our patients had all these critical factors required for development of ifis .
poor
 glycemic control may result in dysfunctions of macrophage phagocytosis , neutrophil
 chemotaxis and oxidative killing ( 1 ) , and ketoacidosis
 may induce a temporary block in binding of iron to transferrin providing free iron which
 enhances growth of many ifis particularly mucormycosis ( 2 , 13 , 14 ) .
poor compliance to therapy as evidenced by poor clinic attendance , risk
 taking behaviors and recurrent admissions for dka has been documented to increase
 susceptibility to ifis ( 12 ) .
similarly malnourished
 state resulting either from a poor glycemic control or poor dietary management predispose
 diabetic children to ifis ( 3 , 10,11,12 ) .
the presence of critical predisposing factors and an unusually high
 occurrence of ifis in our patients is probably a result of the prevailing healthcare
 situation related to the management of t1d in children in our setup ( 15 ) .
late diagnosis of diabetes due to lack of awareness of parents and
 the primary healthcare physicians is common in india ( 15 ) .
poor metabolic control is also common due to
 lack of comprehensive diabetes care ( 15 , 17 ) .
there are only a few specialized centers and
 majority of the patients are treated by the primary care physicians who have limited
 knowledge about the disease and the modern treatment options ( 15 ) .
additionally , poor socioeconomic status often makes even the
 conventional insulin therapy and blood glucose monitoring unaffordable by the parents ( 15 ) .
the prevention of ifis in children with t1d requires
 early diagnosis of diabetes before onset of ketoacidosis , meticulous glycemic control in
 follow up and good nutritional management .
improvements in diagnosis and care of children
 with t1d in our country setup will probably lower the incidence of ifis in these patients in
 future .
establishment of an early diagnosis of ifi is important but is often difficult due to
 absence of specific symptoms ( 5 ) .
we believe that a
 high index of clinical suspicion in a setting of predisposing risk factors present in our
 patients resulted in rapid establishment of diagnosis .
presence of subtle clinical features
 like dry cough , tachypnea persisting after resolution of acidosis , facial swelling ,
 serosanguineous nasal discharge and low grade fever in poorly controlled , malnourished
 children who present in ketoacidosis are pointers to the presence of ifis ( 5 , 11 , 12 ) . in patients
suspected to have rhinocerebral
 involvement , smear examination of scrapings from nasal or sinus cavity are useful aid to
 rapid diagnosis .
the diagnosis of pulmonary ifi is highly probable if the ct scan shows
 cavitary pneumonia in a child with minimal pulmonary symptoms and previously described risk
 factors ( 10 ) .
fine needle aspiration cytology can be
 very useful in reaching an early diagnosis of pulmonary ifis as compared to more invasive
 transbronchial biopsy ( 10 , 18 ) .
the cornerstone of management is a combination of antifungal drugs and early surgical
 debridement of involved tissues that may prevent extension of infection to the surrounding
 areas ( 4 , 19 ) .

treatment with antifungals alone is usually ineffective due to poor concentrations in
 affected tissues resulting from vascular invasion , thrombosis , occlusion and infarction
 ( 4 ) . in our patients who had rhinosinusitis ,
early
 surgical debridement probably prevented a contiguous extension of infection into the brain .

one
 of the 2 patients who received only antifungal therapy died ; the survivor received liposomal
 amphotericin b which had been previously reported to be able to achieve cure even in the
 absence of associated surgery ( 20 ) .
the success rates
 of a multimodal treatment approach in our study are similar to those achieved across many
 centers around the world ( 4 , 5 , 19 ) .
the long term morbidity
 related to consequences of the fungal disease was also minimal and confined to the sequelae
 of tissue loss from radical surgeries . in conclusion ,
rapid and accurate diagnosis of ifis in children with t1d and a multimodal
 management approach involving early surgery , appropriate antifungal therapy and control of
 hyperglycemic state is successful in achieving a good outcome . to the best of our knowledge ,

ours is the largest single center data and the first study from a developing country setup
 on ifis exclusively in children with t1d .

Answer:
abstractthere is scarcity of data on spectrum and outcome of invasive filamentous fungal
 infections ( ifis ) in children with type 1 diabetes ( t1d ) from developing countries .
 a
 retrospective review of medical records of children with t1d hospitalized with ifi over
 the past decade at the pediatric endocrinology and diabetes unit of a large tertiary care
 hospital of north india was performed with an aim to study their clinical spectrum ,
 hospital course and final outcome .
 of the 10 patients studied , nasal / paranasal involvement
 was seen in 6 and pulmonary involvement in 5 patients . one patient developed disseminated
 disease .
 majority of the identified mycoses belonged to class zygomycetes order mucorales .

 early surgery along with antifungal therapy helped limit the extension of infection and
 achieve a good outcome in majority of patients .
 two patients died ; one with a late
 diagnosis of pulmonary mucormycosis and the other with disseminated disease .
 the longterm
 morbidity in the survivors was minimal . in conclusion ,
 rapid diagnosis followed by a
 multimodal approach involving aggressive surgical debridement , appropriate antifungal
 therapy and control of hyperglycemic state is the key to good outcome in this otherwise
 lethal infection .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
familial adenomatous polyposis ( fap ) is an autosomal dominant syndrome caused by a germ line mutation of the adenomatous polyposis coli ( apc ) gene .
surgery for fap aims to minimize colorectal cancer risk while providing good functional and socially acceptable outcomes .
curative surgical treatment is total proctocolectomy with permanent ileostomy , but permanent stoma is an undesirable situation .
total colectomy with ileorectal anastomosis ( ira ) and total proctocolectomy with ileal pouch - anal anastomosis ( ipaa ) are procedures of choice without need for permanent stoma .
the risk of rectal cancer due to the remaining rectal stump in ira continues to be the most important problem .
the risk of developing cancer in the rectal stump is 4 per cent at 5 years and 25 per cent at 20 years .
the result of a meta - analysis showed that functional outcome and quality of life were better after ira than ipaa . on the other hand same meta - analysis show that cancer occurring in 5.5 per cent after ira compared with zero after ipaa .
as the risk of cancer and socially acceptable outcomes are the major considerations in deciding the best operative strategy for patients with fap .
technically it can be more difficult by abdominal approach to transect the rectum just on the dentate line and to perform a ileal pouch - anal anastomosis .
anorectal eversion may allow the assessment of the mucosa under direct visualization and resection remaining very little rectal mucosa and eases the hand - sewn or stapler - facilitated anastomosis .
we report here a patient with fap , who had total proctocolectomy resection via rectal eversion over the dentate line under direct visualization and ileoanal - j pouch anastomosis by double - stapler technique .
a 40-year - old female patient with a family history of colorectal cancer who has multiple adenomatous polyps from 4  cm proximal to the dentate line to the entire colon on colonoscopy was diagnosed as fap .
the operation was performed in the lithotomy position under general anesthesia . through the midline incision
first of all colon and the rectum mobilized completely and routine colectomy was performed from 10  cm proximal to ileo - caecal valve to the rectosigmoid junction by a 50  mm linear stapler ( gia dst , covidien , mansfield , ma , usa ) . by gentle dissection
ileal j - pouch constructed from the distal ileum by a 100  mm linear stapler ( gia dst , covidien , mansfield , ma , usa ) .
the relaxing incisions were made on both sides of the meso - ileum to diminish the tension on the anastomosis .
after the relaxation incision the tip of reservoir easily reaches 3  cm beyond the lower margin of the symphysis pubis . by perineal approach rectal stump irrigation with an antiseptic solution
was done followed by insertion of a grasping forceps through the anus ( picture 1 ) and the rectal stump was everted through the anus by the mucosa turning inside - out ( picture 2 ) dentate line identified and the mucosa evaluated for the polyps . the remaining 15  cm long rectal stump resected just on the dentate line by ta linear cutter ( gia dst , covidien , mansfield , ma , usa ) .
( pictures 3 and 4 ) then ileal j - pouch -anal anastomosis was performed by 29  mm circular stapler ( sdh29a , ethicon , ca , usa ) .
follows at 6th months the patient had no problem related to the anal incontinence and on digital examination anal sphincter functions found normal .
surgical options for fap patients that avoid the need for a permanent stoma include total colectomy with ira and restorative proctocolectomy with ipaa .
ipaa , which was first described by parks in 1978 for ulcerative colitis that permits total removal of all disease - prone mucosa but avoids the need for a permanent ileostomy while preserving anal continence and intestinal continuity .
a meta - analysis showed that functional outcome was better preserved after ira than ipaa for fap , with regard to stool frequency , need for defecation at night , incontinence and the need for pads .
these findings were expected in the patient with a retained , functioning rectum however , surprisingly , ipaa was not significantly different from ira with regard to stool frequency at night , day - time incontinence and need for antidiarrheal medication .
whether stapled or handsewn ipaa offers a better functional outcome has not been determined yet . for ipaa , it has been suggested that functional outcome is better for fap than ulcerative colitis .
it has also been suggested that secondary ipaa , often performed following failed ira is associated with poorer functional outcome .
the most important consideration in deciding the best operative strategy for fap patients is the risk of cancer development .
aziz et al . showed that cancer occurring in 5.5 per cent after ira due to the remaining rectal stump compared with zero after ipaa in a meta - analysis .
it is reported that there is no significant difference between ipaa and ira with respect to bowel obstruction , hemorrhage , intra - abdominal sepsis , anastomotic separation and wound infection in the same meta - analysis .
controversy still exists about the technique to be used for the pouch - anal anastomosis .
mucosectomy and handsewn anastomosis are necessary to remove the rectal mucosa as completely as possible . but
this technique takes longer time and has a relatively high risk of postoperative functional problems related to leakage and incontinence due to prolonged anal manipulation .
stapling ipaa was first described by heald and allen in 1987 and is widely accepted to use for creation of the ileal pouches and ipaa .
however to allow transanal insertion of the stapler head , it is usually unavoidable to leave a 12  cm segment of rectal mucosa over the dentate line that carries a risk of developing adenomas and cancer .
adenomatous polyps , colonic metaplasia , and adenocarsinoma can occur in the terminal ileum of patients with fap , although the long term risk of pouch and dentate line cancer is not known .
studies comparing handsewn versus stapled ipaa have reported variable results . in a study of large number of patients of a single institution
had found that stapled ipaa had better outcomes and quality of life ( qol ) scores than those undergoing a handsewn ipaa .
technical difficulties can still arise with the stapled ipaa technique , particularly with respect to accurate transection and closure of the anal canal at the anorectal junction by abdominal approach .
rectal eversion permits the direct visualization of the mucosa and dentate line and has been suggested as a means of facilitating accurate anal transection and closure by use of either a handsewn purse - string suture or a linear stapler .
however , there has been some concern regarding the potential of anorectal eversion to impair anal continence by causing traction injury to the anal sphincter complex or its nerve supply and thus worsen the functional outcome of restorative proctocolectomy .
williamson et al . reported in a 50 patients series one year after restorative proctocolectomy with rectal eversion , all patients were continent , although two experienced leakage of mucus requiring a pad .
forty - two patients ( 84 per cent ) could discriminate between faeces and flatus .
they noted that the eversion of the anorectum during restorative proctocolectomy impairs the motor and sensory functions of the anal sphincter but most patients achieved satisfactory anal continence , however , despite these physiological changes .
have reviewed the median 4 years follow - up clinical results of consecutive series of 41 patients operated with rectal eversion and reported that no patients had major incontinence and only 2 ( 6% ) had minor leakage .
anorectal eversion may be achieved by the method described above , grasping forceps being introduced transanally to pull down the transected lower rectum , or by an alternative method described by scotte et al .
whereby the lower rectum is cross - stapled over a corrugated drain , introduced transanally , which can be used to facilitate eversion of the anorectum by traction from proximal end point of colon after rectal transection .
we conclude that , to facilitate accurate fashioning of stapled ipaa , anorectal eversion can be put into practice during restorative proctocolectomy .
muhittin aygar : data collection , data analysis , writing ; fahri yetiir : study design , data collections , data analysis , writing ; ebru arer : data collections , data analysis ; murat baki yldrm : data collections ; mesut zdedeolu : data analysis ; doukan durak : data collections ; abdssamet yaln , data analysis .

Answer:
introductionsurgery is the only treatment option for familial adenomatous polyposis ( fap ) .
 aim of surgery in fap is to minimize colorectal cancer risk without need for permanent stoma .
 there are especially two operation options ; total colectomy with ileorectal anastomosis ( ira ) and total proctocolectomy with ileo - pouch anal anastomosis ( ipaa ) .
 we report here a patient with fap who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal - j pouch anastomosis by double - stapler technique.presentation of casea 40 yr .
 old female patient with fap underwent surgery .
 firstly , colon and the rectum mobilized completely , and then from the 10 cm .
 proximal to the ileo - caecal valve to the recto - sigmoid junction total colectomy was performed .
 rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line . a stapled j - shaped ileal reservoir construction followed by intraluminal stapler - facilitated ileoanal anastomosis .
 follow up at six months anal sphincter function was found normal.discussionthere is only surgical management option for fap patients up to now .
 total colectomy with ira and restorative proctocolectomy with ipaa is surgical options for fap patients that avoid the need for a permanent stoma .
 anorectal eversion may be used in the surgical treatment of fap , chronic ulcerative colitis and early stage distal rectal cancer patients.conclusionj-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in fap patients .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
glucose-6-phosphate isomerase ( gpi ) deficiency is the third most common red blood cell enzymopathy , after glucose-6-phosphate dehydrogenase ( g6pd ) and pyruvate kinase ( pk ) deficiency and is similarly associated with hereditary nonspherocytic hemolytic anemia ( hnsha ) .
the sole clinical manifestation in the majority of patients is chronic hsnha , ranging from mild to severe .
most cases of gpi deficiency are diagnosed during the neonatal and childhood period . to date , only two cases of prenatal diagnosis of gpi deficiency have been reported .
additionally , cases of postnatal diagnoses of hydrops caused by gpi deficiency were documented , usually without survival of the affected child 2,3 . in this case report
, we describe a family in which two siblings have congenital hsnha due to gpi deficiency .
the first child was diagnosed at the age of 3  years , the second was monitored antenatally with repeated doppler ultrasound and was eventually treated for fetal anemia with repeated intrauterine transfusions . to our knowledge , this is the first case of prenatal diagnosis of gpi deficiency in cord blood , followed by successful intrauterine treatment of gpi - deficient fetal anemia .
a 33-year - old woman was referred to our center at 17  weeks of gestation because of an increased risk of fetal anemia .
their first child , a 5-year - old girl , was born after an uneventful pregnancy and did not suffer from extreme neonatal jaundice or anemia .
she was diagnosed with gpi deficiency at the age of 3  years after her first documented acute hemolytic episode with signs of jaundice , severe anemia , and hemoglobinuria . following extensive investigation
dna analysis showed the girl to be homozygous for the c.1615g > a , p.(asp539asn ) missense mutation in gpi .
both the mother and father were found to be heterozygous for the same mutation . at present , the girl remains clinically well , has normal growth and neuropsychological development but has evident chronic hemolysis treated with folic acid .
she has had infrequent exacerbations of hemolysis associated with minor childhood infections but nonsevere enough to warrant erythrocyte transfusions .
the current pregnancy was the fourth pregnancy of this couple , following two early miscarriages .
the parents refrained from early diagnostic chorionic villus biopsy or amniocentesis ( because of the risk of miscarriage ) , but instead opted for ultrasound monitoring for signs of fetal anemia ( measurement of the mca doppler peak systolic velocity ( mca - psv ) ) .
the pregnancy was followed up on a weekly basis , from 16  weeks of gestation onward . at 26  weeks of gestation ,
fetal anemia was suspected , based on an increased mca - psv of > 1.5 multiples of the median ( mom ) ( fig.1 ) .
there is suspicion of fetal anemia when vmax in the middle cerebral artery exceeds 1.5  mom .
the first iut was given transplacentally in the umbilical cord root at 27  weeks of gestation .
pretransfusion cord blood was obtained for diagnostic testing , the fetal hemoglobin level was 7.4  g / dl .
an uncomplicated intravenous transfusion of donor blood was performed , resulting in a posttransfusion hemoglobin concentration of 13.5  g / dl .
genetic analysis of fetal cells confirmed that the second child was also homozygous for the aforementioned mutations in the gpi gene .
after the diagnosis was made , folic acid was prescribed to the mother in a daily dosage of 5  mg .
another two iut 's were performed at gestational weeks 30 and 34 ( table1 ) .
based on the fact that the fetus needed repetitive intrauterine transfusions from 27  weeks of gestation onwards , labor was induced at 37  weeks to avoid further intrauterine transfusions .
a girl was born vaginally with apgar scores of 9 and 10 at 1 and 5  min , respectively .
the cord blood ph was 7.25 and her weight was 3620  g. neonatal jaundice was apparent immediately after birth .
the child required no exchange or top - up transfusions and was discharged at day 7 . at 4  weeks of age , despite resolving hemolytic parameters ( decreasing bilirubin and ldh ) the girl remained reticulocytopenic and required an additional blood transfusion for symptomatic anemia .
two weeks after transfusion , spontaneous recovery of hemoglobin concentration was observed , with rising reticulocytes ( 105    10/l ) , normal bilirubin ( 11  mol / l ) , normal ldh ( 241  u / l ) , and low haptoglobin ( < 0.1
she remains well and transfusion - independent at the current age of 5  months , while receiving folic acid replacement therapy .
intrauterine transfusion data for the treatment of fetal anemia volume transfused : volume of transfused red blood cells .
gpi is a dimeric enzyme which catalyzes the reversible conversion of glucose-6-phosphate and fructose-6-phosphate , the second step in glycolysis .
the gpi gene is located on the long arm of chromosome 19 and 31 mutations in the gpi gene are currently listed in the human gene mutation database ( www.hgmd.cf.ac.uk ) .
the majority of these mutations are missense mutations affecting key interactions of the enzyme 's active site 5 .
gpi - deficient patients are either homozygous or compound heterozygous for such mutations , and are clinically characterized by chronic hemolytic anemia with hemolytic crises during infection or after ingestion of hemolytic drugs 6 .
the current therapy consists of blood transfusions and splenectomy for the most severe hemolytic cases 3,7 .
it has been suggested that mutant gpi is inactivated faster with increasing rbc cell age than the wild - type enzyme 8 .
the manifestation in affected fetuses might therefore be milder because of the shorter lifespan of fetal rbcs .
however , if fetal hydrops develops due to gpi deficiency , the prognosis is usually very poor 2,9 . in the literature ,
performed the first prenatal gpi deficiency diagnosis at 28  weeks of gestation by assessing the gpi characteristics in amniotic fluid cells .
gpi deficiency was considered after the neonatal death of a previous child with hydrops . the second child in this family
was diagnosed antenatally as compound heterozygous for two different mutant gpi alleles and received an exchange transfusion after birth , which took place at 35  weeks of gestation 2 .
provided a first trimester gpi deficiency diagnosis on trophoblast cells obtained from chorionic villus sampling 1 . in the present case ,
instead , close fetal surveillance by ultrasound scanning was performed on a weekly basis , to monitor for signs of fetal anemia .
the diagnosis was confirmed by genetic analysis of dna of cord blood cells , sampled before the first iut .
iut is universally accepted as an efficient treatment for fetal anemia . in the leiden university medical center , serving as the dutch national referral center for fetal therapy since 1965 , it was the first time iuts were performed for fetal anemia due to gpi deficiency .
we prescribed folic acid supplementation to the mother to prevent the occurrence of megaloblastic anemia in the fetus .
postdelivery the girl also received folic acid , as is standard in patients with  hemolytic anemia .
this is a well - known phenomenon in children that received intrauterine transfusions and is thought to be induced by reduction in their own erythropoietin production .
the parents are both heterozygous for both mutations suggesting that although they were reported to be nonconsanguineous it is very likely that they stem from a common ancestor .
one possibility could be early exposure to oxidant agents which can trigger episodes of hemolysis . however , obstetric history of the second pregnancy showed no infection or known ingestion of oxidant drugs or food .
whitelaw et  al . also reported a family of two affected siblings with different disease severity 2 .
pointed out that patients with the same mutation and deficient gpi activity can present with varying degrees of anemia and clinical impairment 7 .
our findings confirm that the hemolytic episodes caused by gpi deficiency are unpredictable and emphasize the importance of prenatal monitoring of fetuses at risk . in conclusion , hemolytic anemia due to gpi deficiency can be severe and life threatening during fetal life .
we recommend frequent ultrasound monitoring for prenatal management of pregnancies in which there is an increased risk of fetal gpi deficiency , when parents decline early invasive testing . in this case , repeated intrauterine blood transfusions appeared to be effective for the treatment of severe fetal anemia due to gpi deficiency and may additionally have prevented the development of fetal hydrops and demise .

Answer:
key clinical messagehemolytic anemia due to gpi deficiency can be severe and life threatening during fetal life .
 when parents decline invasive testing , ultrasound monitoring of fetuses at risk is feasible .
 intrauterine transfusion can be effective for the treatment of severe fetal anemia due to gpi deficiency .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
the study population included 1177 patients who underwent different types of cardiac surgeries with cardiopulmonary bypass method at sina private hospital ( isfahan , iran ) , between april 2008 and september 2009 .
all patients underwent a cardiovascular diagnostic procedure requiring the use of a contrast agent for left ventriculography , coronary or carotid angiography , and thoracic and/or abdominal aorta angiography before their surgeries .
thus , the patients requiring emergency dialysis therapy or those that underwent the off - pump method surgery were excluded .
data for the studied patients including demographics , clinical characteristics , laboratory data , medical treatments , angiographic data , ( including amount and type of the contrast agent used ) , comorbid conditions and cardiac procedural data ( including its timing in relation to the preceding angiography ) , were collected by reviewing hospital record files in a computerized database .
the study was approved by the research ethics committee of isfahan university of medical sciences , isfahan sina heart center .
the contrast agent used were meglumine compound 76% ( urografin , bayer , usa ) as hyperosmolar , iopromide 370 ( ultravisit , berlex montville , usa , mfd . in : germany ) and iohexol 300 ( iopaque , iran or omnipaque 300 , usa ) as low - osmolar contrast agents .
use of nonsteroidal anti - inflammatory agents and other nephrotoxic drugs were avoided or withheld for 48 hours before angiography .
postoperative renal risk was assessed using 2 different risk scores of a simplified predictive index for renal replacement therapy after cardiac surgery and a risk score for prediction of contrast - induced nephropathy.9 the main outcome of interest was the incidence of postoperative arf , defined as postoperative serum creatinine > 2 times baseline and/or the need for renal replacement therapy .
the mean value of baseline creatinine was 0.99 mg / dl.6 the obtained results are presented as mean  sd , frequency , and percentage .
comparisons were made using chi - square test or fisher 's exact test for categorical variables and nonparametric test for continuous variables .
the amount of contrast media was entered into the model as both a linear ( continuous variable ) and a dichotomous term ( median or less and greater than median value ) .
multivariable logistic regression analysis was used to identify independent predictors of arf using variables found to have marginal association ( p > 0.10 ) on univariate analysis .
odds ratio ( or ) and 95% confidence interval ( ci ) were constructed to provide an estimate of adjusted risk posed by post - procedural arf .
comparisons were made using chi - square test or fisher 's exact test for categorical variables and nonparametric test for continuous variables .
the amount of contrast media was entered into the model as both a linear ( continuous variable ) and a dichotomous term ( median or less and greater than median value ) .
multivariable logistic regression analysis was used to identify independent predictors of arf using variables found to have marginal association ( p > 0.10 ) on univariate analysis .
odds ratio ( or ) and 95% confidence interval ( ci ) were constructed to provide an estimate of adjusted risk posed by post - procedural arf .
comparisons were made using chi - square test or fisher 's exact test for categorical variables and nonparametric test for continuous variables .
the amount of contrast media was entered into the model as both a linear ( continuous variable ) and a dichotomous term ( median or less and greater than median value ) .
multivariable logistic regression analysis was used to identify independent predictors of arf using variables found to have marginal association ( p > 0.10 ) on univariate analysis .
odds ratio ( or ) and 95% confidence interval ( ci ) were constructed to provide an estimate of adjusted risk posed by post - procedural arf .
of 1177 patients who underwent different types of cardiac surgeries after angiography , arf occurred in 465 subjects , 2 of these patients needed dialysis .
mean dose of hyperosmolar and low - osmolar contrast agents used overall were 1.23 and 1.21 ml / kg , respectively .
baseline clinical features between the two cohorts with and without postoperative arf are listed in table 1 .
postoperative arf was more prevalent in older and male patients ( p = 0.003 and 0.002 , respectively ) , and those with a higher history of hypertension(p = 0.012 ) , but prevalence of other risk factors as well as left ventricular ejection fraction were similar in both group of patients .
there was a significant difference between last pre and post- operative creatinine in both groups ( p < 0.001 ) .
patients with arf were also more likely to have undergone combined coronary artery bypass grafting and valve surgery the same day as angiography and also underwent more postoperative intra - aortic balloon pump insertion ( iabp ) ( table 2 ) .
the patients with arf were more likely to have received higher doses of both hyper - osmolar and low - osmolar contrast agents compared to mean doses ( p = 0.17 and 0.035 , respectively ) .
however , the time interval between cardiac surgery and last catheterization was not different between the patients with and without arf ( p > 0.05 ) ( table 2 ) . clinical and demographic characteristics of the studied population contrast agent and cardiac surgery data overall postoperative peak creatinine was highest on day 0 ( figure 2 ) , then decreased and remained significantly unchanged after this period ( p < 0.05 ) .
however , overall prevalence of acute renal failure during follow - up period ( figure 2 ) had a changeable trend and had the highest rates in days 1 ( 53.57% ) and 6 ( 52.17% ) ( p < 0.05 ) .
relationship between the time interval flanked by angiography and surgery and postoperative serum creatinine relationship between the time interval flanked by angiography and surgery and postoperative acute renal failure independent correlates of postoperative arf in a multivariate model are listed in table 3 .
combined coronary artery bypass grafting ( cabg ) and valve surgery was the strongest predictor of postoperative arf ( or : 4.976 , p = 0.002 ) , followed by intra - aortic balloon pump insertion ( or : 6.890 , p = 0.009 ) and higher dose of contrast agent ( or : 1.446 , p = 0.031 ) .
the major findings of the present study were that the higher dose of the used contrast agents besides some other determinants such as combined coronary bypass and valvular surgery as well as iabp insertion could effectively predict post - procedure acute arf .
on the other hand , the use of high dose of contrast agent was strongly related to the incidence of arf after combined cardiac surgery .
in fact , our data confirmed findings of other investigations that arf after cardiac surgery was associated with the amount of prescribed contrast agents . in a similar study by ranucci and his colleagues,6 cardiac surgery performed on the day of cardiac catheterization and higher dose of contrast agent
although these investigators demonstrated a correlation between the time interval of cardiac catheterization and surgical procedure with the incidence of acute arf , we could not demonstrate this relationship in our multivariable regression model . in another study by del duca
et al4 cardiac catheterization performed within 5 days before operation , baseline glomerular filtration rate of less than 60 ml / min and prolonged cardiopulmonary bypass duration , were significant risk factors for acute renal failure after cardiac surgery . moreover , other studies established similar clinical and surgical characteristics associated with increased risk of arf after cardiac surgery , including age,168 baseline serum creatinine,10 diabetes mellitus,1113 congestive heart failure,1012 emergency surgery,1114 concomitant valve surgery with coronary artery bypass grafting,11 preoperative use of iabp,14 and low cardiac output syndrome in the postoperative course.1415 however , these studies consistently failed to account for the influence of the timing between previous angiography and cardiac surgery and the amount of the contrast agent used in this event .
multiple mechanisms have been suggested to contribute to the renal damage following cardiac diagnostic procedures , including non - pulsatile flow , embolization , and trauma to the blood constituents , hypothermia , and activation of known inflammatory pathways.16 iodinated contrast as a common contrast agent , after causing a brief period of vasodilation , can cause sustained intrarenal vasoconstriction and ischemic injury .
the ischemic injury sets off a cascade of events largely driven by oxidative injury , causing death of renal tubular cells .
if a sufficient mass of nephron units are affected , then a recognizable rise in serum creatinine will occur.1718 therefore , minimizing the amount of contrast agent during preceding angiography is recommended .
similar studies need to be conducted regarding alternate imaging modalities that do not use iodine - based contrast agents to obtain information about ventricular function , valvular dysfunction and aortic pathologic characteristics.6 finally , strategies to prevent contrast - induced nephropathy during angiography that is continued in the postoperative period may also have the potential to decrease arf after early cardiac surgery .
mms designed the study and drafted this manuscript ; mg carried out the study and drafted the tables ; pn carried out the study and drafted the tables ; hsh helped in designing the study ; hms helped in final drafting ; ak helped in designing and carried out the study ; pms data analysis ; and nf data collection .

Answer:
background : there is limited data about the influence of timing of cardiac surgery in relation to diagnostic angiography and/or the impact of the amount of contrast media used during angiography on the occurance of acute renal failure ( arf ) .
 therefore , in the present study the effect of the time interval between diagnostic angiography and cardiac surgery and also the amount of contrast media used during the diagnostic procedure on the incidence of arf after cardiac surgery was investigated.methods:data of 1177 patients who underwent different types of cardiac surgeries after cardiac catheterization were prospectively examined .
 the influence of time interval between cardiac catheterization and surgery as well as the amount of contrast agent on postoperative arf were assessed using multivariable logistic regression.results:the patients who progressed to arf were more likely to have received a higher dose of contrast agent compared to the mean dose . however , the time interval between cardiac surgery and last catheterization was not significantly different between the patients with and without arf ( p = 0.05 ) . overall , postoperative peak creatinine was highest on day 0 , then decreased and remained significantly unchanged after this period .
 overall prevalence of acute renal failure during follow - up period had a changeable trend and had the highest rates in days 1 ( 53.57% ) and 6 ( 52.17% ) after surgery .
 combined coronary bypass and valve surgery were the strongest predictor of postoperative arf ( or : 4.976 , ci = 1.613 - 15.355 and p = 0.002 ) , followed by intra - aortic balloon pump insertion ( or : 6.890 , ci = 1.482 - 32.032 and p = 0.009 ) and usage of higher doses of contrast media agent ( or : 1.446 , ci = 1.033 - 2.025 and p = 0.031).conclusions : minimizing the amount of contrast agent has a potential role in reducing the incidence of postoperative arf in patients undergoing cardiac surgery , but delaying cardiac surgery after exposure to these agents might not have this protective effect .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
unfortunately this demand is more than the supply in terms of surgeons performing these surgeries .
robotic surgery fills the gap between having skills and not having one . a surgeon with limited skills
this leads to added advantage both to the patient as well as the surgeon . notwithstanding the cost , robot helps to duplicate the laparoscopic surgeries which otherwise would be beyond the reach of surgeon with limitation of skills . in april 2005 ,
davinci robot was food and drug administration cleared for gynaecologic procedures based on preliminary evidence of safety and efficacy from their early experience with myomectomy and hysterectomy at the university of michigan .
robotics is best for single quadrant surgery and for fixed structures and hence is especially useful in gynaecological surgery .
it has added advantages of 3d perception , wristed instrumentation , intuitive movements and dexterity .
since november 2009 until date , we have performed 80 robotic gynaecological cases in galaxy care laparoscopy institute , pune .
we standardized the port positions as
 a 12 mm camera port was placed 2 cm above the umbilicus.an 8 mm robotic port on the either side was placed 10 cm lateral and 12 cm caudal to the camera port.the right sided robotic port was a mirror image of the left robotic port.two assistant 10 mm ports were placed pararectally at the level of the camera port .

an 8 mm robotic port on the either side was placed 10 cm lateral and 12 cm caudal to the camera port .
two assistant 10 mm ports were placed pararectally at the level of the camera port .
the robotic cart was docked from in between the legs a zero degree scope was used for the procedure . for all the surgeries ,
robotic docking time.console time surgical time.blood loss.complications.conversion to either lap or open
  robotic docking time .
conversion to either lap or open for the oncological surgeries , other parameters such as paracervical clearance , nodal yield and vaginal margins were also recorded .
of the total of 80 gynecological cases performed robotically in our institute , 29 were benign and 51 were malignant cases .
of the benign cases , 24 were hysterectomies for various complex benign pathologies like big fibroids , previous abdominal surgeries .
2 tubotuboplasties , 1 endometriotic cyst excision , 1 metroplasty , 1 rectovaginal fistula repair were also performed with good results at our institute . of the total of 51 oncological cases performed robotically ,
27 were robotic radical hysterectomies for cancer cervix , 10 total robotic hysterectomies with bilateral salpingo - opherectomy with ilioobturator node dissection for cancer endometrium , 2 were total robotic hysterectomy with bilateral salpingo- opherectomy and omentectomy for cancer ovary , 7 were exenterations , 5 were parametrectomy .
total robotic hysterectomy : we compared our outcomes with those of previously done standard studies as shown in the table 1 .
comparison of our data of total robotic hysterectomy with previously reported series our operative time , estimated blood loss was considerably lower when compared with other standard international studies .
there was no conversion to open surgery ; furthermore no major intraoperative or postoperative complications were noted .
robotic radical hysterectomy : we have compared the results of our radical hysterectomies with those of other standard reported cases in literature . as shown in table 2 our operative time , effective blood loss was less than that of others . two cases of ureteric fistulas reported were during initial phase after acquiring the robot . as we got acquainted with these procedures
comparison of our data of radical robotic hysterectomy with previously reported series table 3 below provides comparison of parameters between our laparoscopic cases with the robotic cases .
total robotic hysterectomy : we compared our outcomes with those of previously done standard studies as shown in the table 1 .
comparison of our data of total robotic hysterectomy with previously reported series our operative time , estimated blood loss was considerably lower when compared with other standard international studies .
there was no conversion to open surgery ; furthermore no major intraoperative or postoperative complications were noted .
robotic radical hysterectomy : we have compared the results of our radical hysterectomies with those of other standard reported cases in literature . as shown in table 2 our operative time , effective blood loss was less than that of others .
two cases of ureteric fistulas reported were during initial phase after acquiring the robot . as we got acquainted with these procedures
comparison of our data of radical robotic hysterectomy with previously reported series table 3 below provides comparison of parameters between our laparoscopic cases with the robotic cases .
the advantages of robotic assistance include enhanced dexterity , improved 3-d vision , and more intuitive instrument manipulation .
it thus helps to bridge the skill gap for a laparoscopic surgeon helping to overcome skill limitations .
this may make a complex surgical task more accessible to surgeons without much laparoscopic experience .
placement of robotic trocars has to be in such a way to prevent collision of robotic working arms and accessory ports .
the accessory ports are used for retraction , for energy sources like ligasure or for applying clips .
the preoperative planning helps in performing a smooth procedure as well as reducing the docking time .
the docking time was previously 30 min which later reduced to 10 min because of standardization of ports , team gaining experience and getting acquainted with the system . in 1989 , laparoscopy was first used to perform a hysterectomy . in 2002 , the use of the davinci robot for hysterectomies was first reported .
payne and dauterive concluded that robotic hysterectomy was quicker and with less risk for abdominal conversion than standard laparoscopy .
we have an extensive experience in laparoscopic hysterectomies with which we have started doing robotic hysterectomies .
the patients with high body mass index and patients with narrow pelvis were preferred for robotic procedure . the time taken and blood loss was the same as in laparoscopy .
standardization of procedure and proper training of the technique was necessary to prevent complications and for safe outcome .
the salient steps of our technique
 use of combined anaesthesia , ergonomic port positioning , use of myoma screw for traction , use of bipolar forceps medial to uterine stump , colpotomy at the level of uterosacral ligaments .

use of combined anaesthesia , ergonomic port positioning , use of myoma screw for traction , use of bipolar forceps medial to uterine stump , colpotomy at the level of uterosacral ligaments .
all our patients had stage iv endometriosis and the rectum and ureter could be separated well due to the high magnification and the intuitive movements of the robot .
robotic - assisted laparoscopic surgery promises to provide advantages in the management of women with severe endometriosis secondary to 3-dimensional visualization , decreasing surgeon 's fatigue and hand tremors and improving surgical precision . with the davinci system
, the challenges of visibility with laparoscopy can be overcome as well as many other limitations of laparoscopy .
hence , the field of gynaecologic oncology has begun adopting the davinci system in performing oncological surgeries due to its shorter learning curve and ease of use .
studies , suggest that robotic radical hysterectomy ( rrh ) is preferable over laparoscopic radical hysterectomy ( lrh ) due to its decrease in blood loss , hospital stay , recovery time , and complications
. however , rrh appears to be equivalent to lrh in the hands of experienced surgeons . in patients predicted to have a high chance for conversion to open from laparoscopy , davinci system may prevent conversion .
the international federation of gynaecology and obstertrics staging requires lymphadenectomy for assignment of stage , and morbid obesity is usually cited as the most common limiting factor for completing a satisfactory lymphadenectomy .
the multi - centre gynecologic oncology group lap-2 trial with 1,696 laparoscopic cases reported a 23% conversion rate and a mean operative time of 3.3 hrs , indicating difficulty with a significant proportion of cases .
reasons for not adopting laparoscopic surgery often cited by surgeons are prolonged operating times , surgeon fatigue , a difficult and prolonged learning curve , and lack of formal training in advanced laparoscopic technique .
we have reported our experience of laparoscopic gynaec oncology procedures such as radical hysterectomy , anterior exenteration and total pelvic exenteration .
the use of hybrid technique and using bipolar energy near the ureters have prevented any further fistulas in subsequent patients .
the two larger series from boggess et al . , and lowe et al . ,
show that there were no transfusions , length of stay was one day , and total complications were less than that usually associated with either open or laparoscopic approaches .
the results are comparable to those of laparoscopy , robot helps to duplicate many procedures with exceptional laparoscopic skills .

Answer:
aims : to study the role of robotics in various gynaecological cases , benign and malignant.materials and methods : a total number of 80 cases have been analyzed .
 operative time , estimated blood loss , hospital stay , complications , conversion rates have been retrospectively studied in all cases .
 nodal yield , vaginal margin and paracervical clearance have been studied in all malignant cases .
 this investigation was conducted at a single minimal access surgery institute.results:of total 80 cases , 29 were benign and 51 were malignant cases . in benign cases , total robotic hysterectomies were 24 , 2 cases of tubotuboplasty , 1 case of endometriotic cyst excision , 1 case of metroplasty and 1 case of rectovaginal fistula . in 51 cases ,
 37 of radical hysterectomy , 9 exenterations and 6 were parametrectomy .
 in benign cases , mean operative time was 80 min , estimated blood loss was 20 ml , mean hospital stay was for 1 day , no major complications and no conversions . in malignant cases ,
 mean operative time was 122 min , estimated blood loss was 50 - 100ml , 2 cases of ureteric fistulas and no conversions , nodal yield was 30 , vaginal margin was 2.5 - 3.8 cm and para cervical clearance was 3 - 3.5 cm.conclusions:ours is the largest series of robotic surgery in gynecological procedures in india .
 benign and malignant cases were addressed robotically showing the feasibility .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
alopecia areata ( aa ) is a chronic inflammatory disease of the hair follicles and nails , its etiology is unknown , probably multifactorial with evident autoimmune and genetic components . the first clinical description of aa is attributed to celsus ( 14 - 37 b.c . ) and the designation aa was given by sauvages .
the importance of genetic factors in aa is underlined by the high frequency of a positive family history in affected individuals . in most reports , these range from 10% to 20% of cases .
a study in monozygotic and dizygotic pairs found a concordance rate of 55% for alopecia amongst monozygotic twins with no concordance among the dizygotic pairs . though it can affect any age group , demographical data on aa is still lacking .
two brothers aged 5 and 7 years presented to the outpatient department with complaints of asymptomatic patchy loss of scalp hair for the past 2 and 4 months respectively .
there was no similar complaint in any other family member , siblings and no history suggestive of systemic involvement , drug intake , trauma , pus filled lesions or any other skin eruptions .
mucocutaneous examination revealed multiple smooth patches of alopecia ranging from 2 cm  2 cm to 4 cm  6 cm over occipital and vertex area of elder child and multiple patches over occipital and temporal region measuring 2 cm  2 cm to 2 cm  4 cm of the younger one [ figure 1a and b ] .
( a ) multiple areas of nonscarring alopecia involving the occipital and vertex area in a 7-year - old child ( b ) multiple areas of nonscarring alopecia involving the occipital and temporal area in sibling 5-year - old surface of the patches was smooth with no apparent changes .
histopathological examination of the biopsy sample from the alopecia patch from the scalp confirmed the diagnosis , which showed inflammatory infiltrate in and around the bulbar region of hair follicle .
alopecia areata is t cell mediated autoimmune disease with genetic predisposition resulting in partial and total nonscarring alopecia .
scalp is the predominant site of involvement with the most common clinical pattern involving multiple areas of patchy hair loss .
most patients develop aa before the age 40 years with 11 - 20% of all cases occurring in children .
the ratio of male : female in aa in pediatric age group is 1:1 where as in adolescent and adult it is more common in female .
human leukocyte antigen ( hla)-dq3 and hla - dqb1fnx0103 alleles appear to be marker for genetic susceptibility to aa with the latter serving as a special genetic marker for more severe variants .
the diagnostic pathologic feature is peribulbar lymphocytic inflammation ( swarm of bees ) predominately cd4 + cells along with cd8 + t cells affecting anagen follicles or follicles in early catagen .
short , easily extractable broken hairs , known as exclamation mark hairs , are often seen at the margins of the bald patches during active phases of the disease .
the scalp is the first affected site in most cases , but any hair - bearing skin can be affected .
the term alopecia totalis is applied to total or almost total loss of scalp hair , and alopecia universalis is the loss of all body hair .
children with aa demonstrate an increased levels of activated t cells leading to various autoimmune diseases like vitiligo , thyroiditis , connective tissue disorders , lichen planus , type 1 diabetes , and pemphigus foliaceous .
geometric and superficial pits are typical of aa whereas deep and irregularly distributed pits are seen in psoriasis and atopic dermatitis . familial aggregation of aa has been studied and it has been found that estimated lifetime risk has been 7.1% in siblings , 7.8% in parents , 5.7% in offspring .
aa has been also reported after allogenic bone marrow transplantation from an affected , hla matched sibling .
menon and kiran reported a case of concomitant occurrence of aa in the sibling with emphasis on environmental precipitating factors .
evidence based management of aa in children is limited due to the lack of well controlled randomized studies .
reassurance should be given to patients with limited disease as spontaneous remission occurs in 80% of patients .
various treatment options tried in aa are topical , intralesional , and systemic corticosteroids , topical immunomodulators , and topical irritants like dithranol , psoralen plus ultraviolet a therapy , excimer laser therapy .

Answer:
alopecia areata ( aa ) is a t cell mediated autoimmune disease with multifactorial etiology resulting in partial and total nonscarring alopecia .
 we hereby report a case of two brothers ( aged 7 and 5 years ) presenting with coincidental aa over scalp which is a rare presentation .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:

				 the prevalence of childhood obesity has been increasing at unsettling rates across the globe .
in addition to striking the developed world , this pattern has also been noted in developing countries undergoing rapid epidemiological transitions , including those in east africa . in sudan , a study of children in secondary school in the capital khartoum found that rates of overweight and obesity were 28.5% and 5.6% , respectively .
rates of obesity for younger schoolchildren in east africa remain unclear , though obesity at younger ages may carry greater importance because younger children possess improved potential for early intervention .
hypertension , a notable sequela of obesity , was already common in sub - saharan africa   but has been reported to be worsening in prevalence in recent years .
hypertension often goes underdiagnosed in children , in part because its accurate diagnosis requires the use of standardized growth charts specific for age , gender , and height , with hypertension defined as a systolic and/or diastolic blood pressure > 95th percentile and pre - hypertension defined as systolic and/or diastolic blood pressure 9095th percentile .
underdiagnosis of hypertension may be even more common in developing countries , where medical care is limited to symptomatic diseases , and childhood hypertension has been overlooked in lieu of more urgent disease .    given the importance of childhood hypertension and pre - hypertension in determining adult cardiovascular disease outcomes , our goal was to determine the prevalence of hypertension and pre - hypertension among urban school children in sudan and to determine whether hypertension was associated with obesity in this population .
these data serve to alert providers in developing and developed countries to the extent of the current obesity epidemic .
sudan is in east africa , bordering egypt on the north , ethiopia on the east , kenya , uganda , and congo on the south , and central african republic , chad , and libya on the west .
sudan has 2.5 million square kilometers and 37 million inhabitants , of whom 57 million live in the capital of khartoum .
traditionally an impoverished country , sudan has experienced an economy that has expanded rapidly with oil exportation over the past 10 years , with khartoum being the epicenter of economic activity .
this was a cross - sectional study using a sample of 304 children aging six through twelve years from two schools randomly selected in khartoum , the capital of sudan .
all students were given a questionnaire to be filled out by their parents , which asked for signed consent for their child to participate in the study , in addition to other demographic and health information .
ethics approval was obtained from the university of medical sciences and technology ( khartoum , sudan ) research ethics board .
questionnaires sent to parents inquired regarding the child 's age , gender , and health conditions , both previous and current .
the questionnaire also asked whether there was a medical diagnosis of hypertension , diabetes , or heart disease among blood - related family members and which family members were affected .
the child was classified as having a positive family history only if disease was present in a first - degree relative .
body weight was measured to the nearest tenth of a kilogram on a calibrated digital scale , with the child 's shoes removed .
height was measured with the child standing with shoes removed , measured in centimeters to the nearest millimeter .
blood pressure was measured twice , once manually and once digitally , using an appropriate cuff size , based on arm circumference , and the mean was taken and used for analysis .   body mass index ( bmi ) , defined as body weight in kilograms divided by the square of height in meters ( kg / m ) , was used as the measure of obesity in this study .
bmi is an accepted measure of obesity in clinical practice , and its use in children has been supported internationally by the international obesity task force ( iotf ) , which agreed that it provides a reasonable index of adiposity   and in that it is a simple and inexpensive measure .
it provides reliable estimations , with the exceptions of extremes of age , height , and musculature .
bmi was categorized according to the centers for disease control and prevention ( cdc ) age-   and sex - specific growth charts .
the following categories were used : underweight < 5th percentile ; normal weight , 5th to 85th percentile ; overweight , 85th to 95th percentile ; obese , > 95th percentile .
blood pressure was categorized according to bp tables from the fourth report on the diagnosis , evaluation , and treatment of high blood pressure in children and adolescents , using age and height percentiles , with normotension defined as a bp under the 90th percentile , prehypertension 90th to 95th percentile , and hypertension greater than 95th percentile or an absolute systolic bp ( sbp ) of 120  mm  hg or diastolic bp ( dbp ) of 80  mm  hg .
children were also classified as hypertensive if they were taking antihypertensive medication or had been diagnosed with hypertension previously .
descriptive statistics were calculated for gender , family history , and bmi and bp categories .
analyses were performed using the chi - squared test for association , and multinomial logistic regression to investigate the odds of systolic and diastolic prehypertension and hypertension with overweight or obesity , controlling for family history of hypertension .
analyses were conducted using stata 10.0 ( 2008 statacorp lp , college station , tx ) .
complete data on height , weight , bp , and family history were available for the entire sample ( n = 304 ) .
the average age of participants was 7.8 years , with a median age of 9 years ( range 612 years ) .
all were of sudanese nationality , and the gender distribution was 236 female ( 77.6% ) and 68 male ( 22.4% ) .
the number of children who were overweight was 45 ( 14.8% ) , and 32 were obese ( 10.5% ) .
females had a nonsignificant trend toward higher rates than males of overweight ( 14.0% versus 11.8% ) and obesity ( 11.0% versus 5.9% , p > .05 ) .
prehypertension was detected in 15 ( 4.9% ) participants and additional 15 ( 4.9% ) had hypertension , all on the basis of bp measurement , as none were taking antihypertensives or had a previous diagnosis of hypertension .
the rate of elevated bp ( prehypertension and hypertension combined ) in males and females was 13.2% versus 8.9% .
a family history of hypertension was reported for 64 ( 21.1% ) of the participants overall , including 20.1% of children with a normal blood pressure , 20.0% of those with pre - hypertension , and 40.0% of hypertensive children ( table 2 ) . though there is a higher rate of family history with hypertension compared to normal bp or prehypertension , this difference was not significant by chi - square test ( p > .05 ) .   regarding the association between bmi and bp , 31.2% of obese children had hypertension , versus 17.8% of overweight children and 5.3% of normal bmi children .
these results were found to be highly statistically significant by pearson chi - squared test ( p < .001 ) .
further classification of prehypertension and hypertension into systolic and diastolic is stratified by bp category in table 3 for descriptive purposes .
the results are given as the relative risk of being in a certain bp category by weight category compared to children with a normal bmi , adjusting for gender and family history .
after adjustment for these factors , sudanese children who were obese had a relative risk of systolic hypertension of 14.7 compared to their normal - weight counterparts ( p < .01 ) .
we found a high rate of overweight and obesity among 612-year - old primary schoolchildren in urban sudan , with 14.8% of the children overweight and 10.5% obese . despite moderate rates of hypertension reported previously among children in sub - saharan africa  up to 11% in rural children , suggesting an underlying genetic predisposition we found that obesity and not family history was the factor most strongly associated with hypertension in our sample .
obese children carried a relative risk of 14.7 for systolic hypertension after adjustment for family history , while family history of hypertension was not significantly associated .
that obesity was so highly correlated with hypertension in a part of the world more commonly linked to undernutrition underscores the pervasiveness of the obesity epidemic and its sequelae throughout the world .
rates of hypertension in sub - saharan africa have been noted to be increasing among adults [ 5 , 6 , 13 ] concurrent with rising rates of obesity in urban areas .
prior studies to demonstrate these effects among children in east africa have been lacking , however .
the appearance of early cardiovascular sequelae of obesity at these young ages suggests that urban areas in the developing world may begin to face increasing health concerns in children related to the obesity epidemic . as in other sub - saharan african nations ,
these high rates of obesity in sudan are felt to be due to the epidemiological transition that has come with westernization .
while food availability has improved , dietary habits have shifted away from traditional agricultural choices to an increase in processed foods as seen in western countries .
the appearance of obesity - associated hypertension in children may signal that developing countries are likely to face similar difficulties as developed countries in overcoming lifestyle choices .
similar reports of obesity have been reported from other less - developed nations outside of africa .
a study of schoolchildren in beijing , china , reported that approximately 20% of children were overweight or obese . in karachi ,
pakistan , an almost identical prevalence of 25% of children had a high bmi , with 6% of children overweight and 19% obese . in iran ,
rates of hypertension in other populations are less clear , although increasing bmi has been consistently associated with increased blood pressure throughout childhood [ 1719 ] .
the total number of children involved was relatively small ( 304 subjects ) , particularly with respect to boys ( 68 subjects ) .
in contrast to many studies of blood pressure in african children that did not determine rates of hypertension based on normal ranges for height , age , and gender , we determined blood pressure status for each of our participants , dividing children into normotensive , pre - hypertensive , and hypertensive categories .    in common with other studies [ 20 , 21 ]
, we used the average of blood pressure measurements at a single time point for each subject , acknowledging that measuring blood pressure on separate occasions is necessary for the diagnosis of hypertension on a clinical basis .
it is possible that the prevalence of hypertension in our sample would be lower were three measurements used to determine hypertension .
other measurements estimating adiposity ( waist circumference , bioelectrical impedance , and mri ) are more specific to the amount of fat mass .
nevertheless , for population - based studies bmi correlates well with these other measures and remains widely used as a definition of obesity in hypertension research [ 2325 ] .
in conclusion , primary schoolchildren in urban sudan exhibited a high degree of overweight and obesity , and hypertension among these children was more closely linked to obesity than to family history . that obesity - associated cardiovascular sequelae exist in the developing world at such young ages
is a harbinger of worsened cardiovascular outcomes in sub - saharan africa in the future . to overcome these trends , children in urban settings in africa are likely to require similar dietary and activity lifestyle adjustments as needed by their counterparts in developed nations

Answer:
cardiovascular disease ( cvd ) frequently has roots in childhood , including following childhood - onset hypertension .
 incidence of cvd has increased in developing countries in east africa during recent urbanization .
 effects of these shifts on childhood hypertension are unclear .
 our objectives were to ( 1 ) determine the prevalence of hypertension among primary schoolchildren in khartoum , sudan ; ( 2 ) determine whether hypertension in this setting is associated with obesity .
 we performed a cross sectional study of 6 - 12y children from two schools randomly selected in khartoum , sudan .
 height , weight , bmi , bp and family history of hypertension were assessed .
 age- , height- and gender - specific bp curves were used to determine pre - hypertension ( 9095% ) and hypertension ( > 95% ) . of 304 children , 45 ( 14.8% )
 were overweight ; 32 ( 10.5% ) were obese ; 15 ( 4.9% ) were pre - hypertensive and 15 ( 4.9% ) were hypertensive .
 obesity but not family history of hypertension was associated with current hypertension . in multiple logistic regression , adjusting for family history , children who were obese had a relative - risk of 14.7 ( ci 2.45 - 88.2 ) for systolic hypertension compared to normal - weight children . we conclude that overweight and obesity are highly prevalent among primary schoolchildren in urban sudan and are strongly associated with hypertension . that obesity - associated cardiovascular sequelae exist in the developing world at young ages
 may be a harbinger of future cvd in sub - saharan africa .


Question:
You will be shown the title of a chemistry paper, together with sections excerpted from the body of the paper. The paper sections may include HTML tags like `<p>` and `</p>`; please ignore these. Your task is to write an abstract for the paper. Your response should include the abstract and no other text.

Title:
2D magnetic MOFs with micron-lateral size by liquid exfoliation

Paper sections:

scalable as it only provides very small quantities of the 2D material, thus preventing its use in important applications such as membranes, 18 sensors 19 or catalysis. 20 On the contrary, the quality of the layers obtained by liquid exfoliation is much lower since the sheets are typically damaged by the solvents used for their separation and stabilization. 21 In addition, the size of the exfoliated layers is typically much smaller and it is very difficult to go down to the monolayer. However, this approach provides an attractive, simple and scalable method for the creation of ultrathin nanosheets from layered materials, which can be applied to MOFs. 22 In view of these features, a challenging goal is to obtain 2D nanomaterials with micrometer-scale lateral dimensions and nanoscale longitudinal dimensions via liquid exfoliation, which would benefit from an easy processability while retaining the structural integrity.

Herein we demonstrate the production of nanosheets of good quality of 2D magnetic MOFs with lateral sizes of several microns using a liquid exfoliation approach. The compounds of interest are the so called MUV-1-X (MUV = Material of the University of Valencia), a family of layered coordination polymers of formula [Fe(bimX) 2 ] (HbimX = benzimidazole functionalized in the 5-position with X = H, Cl, Br, or CH 3 ). Very recently we have shown that they can be exfoliated down to the monolayer using a dry micromechanical procedure. 11 These crystalline materials are formed by tetrahedral Fe(II) centers linked via benzimidazolate bridges in order to form neutral layers of square Fe(II) networks separated by weak van der Waals interactions. From a magnetic point of view they behave in bulk as canted antiferromagnets ordering at ca. 19-20 K.

MUV-1-X single crystals (X = H, Cl, Br, or CH 3 ) were prepared following the solvent-free methodology previously used by our group. 11,23 Crystals of MUV-1-Cl were used as model compound of this family in order to assess the best conditions for the liquid exfoliation, analysing the effect of different parameters such as source of energy, solvent, time, temperature, concentration, and centrifugation. The exfoliation process is illustrated in Figure 1.

2.5 mg of MUV-1-Cl was initially added in 20 ml of a given solvent, which was subsequently introduced both in a sonic bath and in the sonication tip to examine the impact caused by the source of sonication in the structure of the material. As has been previously established, 22 the tip-assisted sonication can reach higher power than the bath-assisted sonication, resulting in the fragmentation onto smaller crystals with undefined morphologies. This is clearly evidenced in our case, where the sonication tip causes the disintegration of the material, whereas the sonication bath successfully induces the delamination (see Figures S2 and S3). In fact, the damage to the flakes is much reduced when the sonication bath is applied at low temperature using an ice bath.

The different solvents that were used in order to study their relevance in the delamination process were selected due to their different properties: hydrogen bond donors, hydrogen bond acceptors and non-polar solvents. Specifically, we tested water, acetonitrile, diethyl ether, methanol, propanol, acetone, tetrahydrofurane, hexane, dichloromethane, and dimethylformamide. Delamination was successful with most of these solvents, with nanosheets of large lateral sizes observed with optical microscopy and Transmission Electronic Microscopy (TEM) (see Table S1 and Figure S4-S18). However, the behaviour of the exfoliated flakes differs with the solvent, with decomposition or agglomeration found in some cases in several hours (see Table S1), as shown by Raman spectroscopy and TEM (see Figures S4-S18). Only acetone and acetonitrile are found to be suitable solvents for a correct delamination, with higher stability and quality flakes observed for the former. In fact, exfoliated flakes are stable for several days in a colloidal suspension in acetone at low temperatures (see Figures S19 and S23).

After establishing the best solvent and source of energy to proceed with the delamination, we optimized the exposure time and concentration used in the exfoliation process. First, the delamination was analysed by changing the exposure time of the coordination polymer to sonication, resulting in a greater number of flakes with a large lateral size and small thickness in one hour. A reduced time of sonication causes a low delamination, resulting in very thick nanosheets, whereas a longer time of sonication causes the fragmentation of the nanosheets, resulting in very small lateral size (see Figures S24-S33). Second, we studied the effect of concentration on the exfoliation process, varying it from 0.0625 mg/mL to 0.75 mg/mL. An optimized concentration was 0.125 mg/mL, with ca. 20% of the material successfully exfoliated; at lower concentration, practically no exfoliation was detected (see Figure S34). Finally, a study was carried out using different centrifugation conditions. This aspect was very important as it allowed us to achieve dispersions with homogeneous thicknesses (Figures S35-S42). The point at which the flakes were obtained with a more effective compromise between quantity and thickness is centrifuging at 8000 rpm, for 1 hour and maintaining a temperature of 5 °C. The low temperature used in the centrifugation was shown to be critical, as also the storage temperature, which prevented the agglomeration and decomposition of the exfoliated material. Using the above optimized conditions, we proceeded to an in-depth characterization of the exfoliated nanosheets of MUV-1-Cl. The

MUV-1-X Exfoliated nanosheets

MUV-1-X Isolated nanosheet <<< MUV-1-X Bulk  isolation of the nanosheets were conducted by spin coating on Si/SiO 2 substrate a few drops of the top of the colloidal solution containing the exfoliated material, resulting in large amount of material (see Figures S43-S45). In this way flakes of different thicknesses and lateral sizes were isolated. Figure 2 shows flakes with lateral sizes much larger than previously reported, achieving values larger than 8 µm (additional AFM images can be found in Figures S46-S48 in the Supporting Information), with thicknesses as low as 4 nm, corresponding to 3-4 layers. Although this is still far from the results obtained with purely inorganic materials, which are of the order of several microns of lateral size, 24 exfoliated MUV-1-Cl flakes are much larger than other exfoliated 2D MOFs, with typical flakes of the order of 0.1-2 µm lateral sizes. 21 Figure 3 shows the characterization of the exfoliated MUV-1-Cl flakes using Raman spectroscopy, AFM and Selected-Area Electron Diffraction (SAED). This multi-technique analysis allows the unequivocal demonstration of the chemical composition of the material, which has not been damaged after delamination. Quite remarkably, SAED reveals that the crystallinity of the material is maintained after liquid delamination.

In addition, different members of the isoreticular MUV-1-X family, with X = CH 3 , Br, and H, were successfully exfoliated following the same protocol as the established to delaminate MUV-1-Cl, achieving in all cases very similar results (Figure 3 and Figure S49-S64). This indicates that the proposed methodology is valid for the different materials with different surface properties.

As far as the magnetism of these 2D MOFs is concerned, we noted that the magnetic signal of these flakes is too weak to be detected through conventional SQUID measurements. Still, a spectroscopic technique such as electron paramagnetic resonance (EPR) has shown to be very useful in this context. Thus, EPR of a suspension in acetone of few MUV-1-Cl flakes, which are intrinsically EPR silent, shows a sextet signal that can be assigned to a Mn 2+ impurity, which is present in the acetone solvent (Figure 4 and Figure S66). This sextet corresponds to a hyperfine coupling constant of 96 G (A = 270 MHz), compatible with the weak crystal field coming from oxygen-based Mn 2+ complexes, such as [Mn(H 2 O) 6 ] 2+ . 25 Interestingly, this Mn 2+ sextet is shifted towards lower fields below a temperature of 16-18 K, which is close to the ordering temperature of the bulk material (19-20 K). This strongly suggests that the ultrathin flakes retain the magnetic ordering of the bulk, showing small differences in the T c value that may be due to dimensionality effects, 9 or simply to the distortion in the layers caused by the exfoliation process. The origin of this shift may be a consequence of the Zeeman splitting caused by the internal magnetic field created by the layers in the weak ferromagnetic state, which has to be added to the applied magnetic field. This requires close contact between the Mn 2+ impurity and the sheets. We speculate that in the acetone suspension, Mn 2+ is probably adsorbed on the surface of the sheets, or even coordinated to terminal benzimidazole ligands located at sheet defects. Similar magnetic shifts were previously observed in hybrid molecular magnets obtained upon insertion of paramagnetic metallocenium cations into layered oxalate magnets.

26

In summary, this work shows the possibility of exfoliating the layered coordination polymers MUV-1-X using a liquid exfoliation method to obtain suspensions of magnetic 2D MOFs of high-quality, formed by layers with lateral sizes of several microns and very low thickness (down to 4 nm). Interestingly, these magnetic nanosheets maintain their structural integrity and the magnetic ordering. This study paves the way for the use of these metal-organic nanosheets in functional heterostructures via a chemical approach which is unachievable by dry exfoliation.

Answer: The isolation in large amounts of high-quality flakes of 2D MOFs remains a challenge. In this work, we develop a liquid exfoliation procedure to obtain nanosheets for a whole family of Fe-based magnetic MOFs, MUV-1-X. High-quality crystalline layers with lateral sizes of 8 µm and thicknesses of 4 nm, which keep the structural integrity and magnetic properties, are obtained.Since the discovery of graphene, other layered materials formed by one or few atomically-thin layers (aka. 2D materials) have been isolated. 1,2 In this context, 2D MOFs are emerging as an important class of 2D materials of current interest, 3 in different areas such as catalysis, 4 membranes, 5 energy, 6 electronics, 7 or magnetism. 8 In magnetism for example, these 2D MOFs have shown to provide unique examples of magnetic layers which, in contrast to the 2D inorganic analogues, 9 are chemically stable and more versatile from the point of view of their functionalization. 10-12Both top-down -involving the exfoliation of crystalline layered materials 13 -and, to a less extent, bottom-up methodologiesinvolving a direct synthesis of the 2D material from molecular precursors 14 -have been used to obtain 2D MOFs. Within the group of top-down methodologies, two different techniques have been developed to obtain nanosheets from the bulk, namely micromechanical 15 and liquid exfoliation approaches. 16 The quality of layers that can be obtained using these two approaches is very different. The micromechanical exfoliation, also known as the Scotch-tape method, allows to separate the layers without any interaction with solvents, thus affording very high-quality layers, which are necessary to explore the physics in the 2D limit. 17 However, this dry approach is extremely difficult to apply to MOFs due to the fragility of the coordination compounds. 10 In addition, it is not


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
as in other countries worldwide , the number of traffic accidents in turkey is increasing each year , from 500,664 in 2000 to 1,034,435 in 2010 .
the high number of traffic accidents yielding injuries and fatalities makes them of great importance to emergency departments ( ed ) .
it is thought that by determining common injuries resulting from accidents and by taking the necessary precautions , morbidity and mortality could be reduced .
the material damage resulting from accidents has a strong adverse effect on a country s economy .
physicians who are aware of the costs of traffic accidents will be able to take a more cost - effective approach to trauma . by retrospectively evaluating the files of patients who presented at hacettepe university medical faculty adult ed because of traffic accidents between 2000 and 2010 , this study aimed to determine the epidemiology of traffic accidents and to analyze the costs .
it was determined that between 1 january 2000 and 31 december 2009 , 3712 patients presented at hacettepe university adult ed following traffic accidents .
for all the patients included in the study , a record was made of various demographic and epidemiological characteristics such as age , gender , arrival time , arrival condition , time to arrival at hospital , presence of any life - threatening condition , glasgow coma score , revised trauma score ( rts ) , findings and results , outcomes ( admittance to hospital , self - discharge , death ) , and length of stay ( los ) in the ed .
injuries were evaluated separately as head , thorax , abdomen , extremities and other injuries .
the details of costs pertaining to that date with the patient file number were recorded .
mean costs per capita were calculated separately for each year , and then the mean cost for each year was converted to american dollars according to the mean exchange rate for that year .
differences between groups were evaluated by kruskall - wallis , mann - whitney , and wilcoxon tests according to variable type and parametric test assumptions .
the study comprised an examination of 2003 patient files that could be accessed from a total of 3712 patients who presented at hacettepe university medical faculty ed following traffic accidents between 1 january 2000 and 31 december 2009 .
the patients included in the study were 901 females ( 45% ) and 1102 males ( 55% ) with a mean age of 39.6816.15 years ( range 1593 years ) . when the years were examined , the most presentations following traffic accidents were in 2004 with 307 ( 15.4% ) , followed by 2005 with 287 ( 14.3% ) .
the highest incidence was seen in the months of may , july , and june , with 217 ( 10.8% ) in may and the lowest number of presentations was in february and march at 120 ( 6% ) for each month . when the distribution of cases was calculated according to season , it was determined that the most of 28.4% of presentations occurred in the summer months . in respect of the time of presentation
, it was determined that the most presentations ( n=671 , 33.5% ) were between 6 pm and 12 am ( midnight ) ( table 1 ) . in the evaluation of the time taken to reach the emergency department ,
it was determined that 51.5% presented within the first 30 minutes after the accident , 76.5% within the first 60 minutes , and 88.7% within the first 2 hours ( table 2 ) .
most patients ( 1675=83.6% ) arrived at the ed by ambulance . according to the manner of injury in the patient records , 1907 ( 95.2% ) were from motor vehicle accidents ( table 3 ) .
the most frequently seen trauma was head trauma ( 18.3% ) , followed by extremities ( 16.7% ) , thorax ( 7.3% ) , and abdominal trauma ( 3.5% ) .
distribution of the outcomes according to the age , glascow coma scale(gcs ) and revised trauma scores(rts ) were given in table 6 .
the results as to whether or not there were life - threatening conditions according to the forensic reports written in the ed are given in table 8 .
mortality occurred in 7 patients ( 0.4% ) who had been given a non - life - threatening report .
the costs of 1998 patients in this study were evaluated and the costs of 5 patients were not evaluated .
the mean cost was found to be 983.54364.4 tl ; minimum 3 tl , maximum 84,941 tl .
the costs for each year were converted to american dollars using the mean exchange rate for that year .
the study examined 2003 records that could be accessed from a total of 3712 patients who presented at hacettepe university faculty of medicine emergency department following traffic accidents between 1 january 2000 and 31 december 2009 .
the patients were 901 females ( 45% ) and 1102 males ( 55% ) , which is similar to the sex distribution found in the literature .
the age of patients in the study ranged from 15 to 93 years , with a mean age of 39.6816.15 years .
reported a mean age of 35.814.3 years , marmor et al . reported 27 years , and etinolu et al . reported 35 years [ 36 ]
this mean age of traffic accidents affects the young and productive population ; therefore , in addition to financial loss , there is thought to be a loss to the workforce and daily functioning .
when the number of traffic accidents was examined according to year , the lowest number was 83 ( 4.1% ) in 2000 .
this result may be due to a lack of records in the past and it is thought that positive steps have been taken over the years in improving recording systems .
highest numbers of presentations occurred in may , july , and june . in a study by varol et al . , the most accidents occurred in august ( 17.9% ) .
the observation that most traffic accidents occur in the summer months agrees with data in the literature .
this may be due to evening rush - hour traffic congestion , limited visual fields at night , and human error due to tiredness , lack of attention , and alcohol intake .
the hours of most presentations were found to be 6 pm to 12 am ( midnight ) in a study by aygencel et al .
, 12 pm ( noon ) to 6 pm by beyazta et al . , and 3 pm to 7 pm by mishra et al . .
in the current study , 1607 patients ( 83.62% ) were brought to the ed by ambulance .
as 52.5% in a similar study . in a previous epidemiological study of trauma in turkey , patient transfer by ambulance
the increase in this rate is thought to be due to use of the  112  ambulance system having become effective and public awareness of first aid and emergency procedures .
the ed was reached within the first 30 minutes after the accident by 51.5% of the patients in the current study . in a study by wong et al . , the mean period before reaching hospital was 28 minutes .
the period before reaching hospital is known to be significant for mortality and morbidity . of the patients in the current study ,
the mortality rate associated with the motor vehicle accidents was 46 ( 2.4% ) and 1 ( 1.6% ) with motorcycle accidents .
eken et al . showed a mortality rate in motorcycle accidents of 5.7% . in a study by mon et al . , the injury and mortality rate of motorcycle accidents was 3.5 times higher than that of other motor vehicle accidents .
the result of the current study is at the expected level as there is widespread motorcycle use in ankara .
the most frequently determined pathology was head trauma ( 18.3% ) , followed by extremity trauma ( 16.7% ) , and these results agree with the literature . taking these results into consideration , precautions giving protection in the event of an accident should be considered a priority in motor vehicle safety equipment . in a study by weninger et al . , head trauma occurred in 66% of patients , thoracic trauma in 55% , abdominal trauma in 55% , spinal trauma in 27% , at least 1 long bone fracture in 70% , and multiple fractures in 51% .
a reason that these rates are higher than those of the current study could be that only high velocity motor vehicle accidents were included in that study . in the current study ,
1639 patients ( 81.8% ) were discharged from the ed , 248 ( 12.4% ) were hospitalized , and 48 ( 2.4% ) died .
reported that 89.7% of patients were discharged from the ed , 8.4% were hospitalized , and 1.1% died .
it is necessary to have monitoring in different departments of patients who have been stabilized by initial interventions , both in terms of patient morbidity and ed turnover . in the current study ,
the average los in the ed was 4031416 minutes , with a median of 180 minutes . in a study by mishra et al .
, 10% of cases spent less than 1 hour at the hospital , 41.6% spent 16 hours , and 48.3% spent more than 6 hours . in the current study , only los in the ed was calculated and the total los in the hospital was not included .
this excessive period and the low rate of hospitalization may be associated with a bed shortage in our hospital . in the current study ,
this is an expected outcome due to factors such as comorbidities and weaker compensation mechanisms in the elderly .
traffic accidents constitute the great majority of criminal cases that present at the ed . of criminal cases presenting at the emergency department ,
in the current study , 7 patients ( 0.4% ) died who had been given an emergency department report that there was no life - threatening condition . in the light of this result , it is thought that it is necessary to be very thorough in the preparation of forensic reports , and physician training on the writing of such reports should be reinforced .
annual losses to the turkish economy of 350450 million dollars are caused by traffic accidents . in the current study ,
the mean cost per capita was found to be 9834364 tl ( 7553357 dollars ) .
if labor force and functional losses are considered , this amount could be much higher .
1910 pounds sterling by morris et al . , and 3600 euros by jacobs et al . .
when compared with these studies , the mean cost of the current study was lower , which may be due to differences in economic status and costs of healthcare in various countries .
removing unnecessary tests would reduce costs , but the basic solution is to increase preventive measures against traffic accidents and driver education must be improved .

Answer:
backgroundtraffic accidents are ranked first as the cause of personal injury throughout the world .
 the high number of traffic accidents yielding injuries and fatalities makes them of great importance to emergency departments.material/methodspatients admitted to hacettepe university faculty of medicine adult emergency department due to traffic accidents were investigated epidemiologically .
 differences between groups were evaluated by kruskall - wallis , mann - whitney , and wilcoxon tests .
 a value of p<0.05 was accepted as statistically significant.resultswe included 2003 patients over 16 years of age .
 the mean age was 39.616.1 and 55% were males .
 admissions by ambulance and due to motor vehicle accidents were the most common . in 2004
 the rate of traffic accidents ( 15.3% ) was higher than the other years , the most common month was may ( 10.8% ) , and the most common time period was 6 pm to 12 am ( midnight ) .
 about half of the patients ( 51.5% ) were admitted in the first 30 minutes .
 life - threatening condition was present in 9.6% of the patients .
 head trauma was the most common type of trauma , with the rate of 18.3% .
 mortality rate was 81.8% .
 the average length of hospital stay was 403 minutes ( 6.7 hours ) and the average cost per patient was 9834364 tl.conclusionsfurther studies are needed to compare the cost found in this study with the mean cost for turkey .
 however , the most important step to reduce the direct and indirect costs due to traffic accidents is the prevention of these accidents .